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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS 0\},N I]R I} U I I,I)ER DF]1.('A RA'I'ION t heeby affirm unda poalty of po'jury that I an qcmpt ftom thc ContracloB' Licme taw for thc following rcmn (56.7031.5 Buincs and Prcfsion Code): Any City or County which rcquiG a pcrmit to construcl. altq. improvq dcmolish or rqhir my struclwc, prior to its issuscc: abo rcquiE thc applicdt for such pcmit to filc a signc{ stalmot thal hc or shc is liccnsd pl$fft to thc provisions of thc Contractor's Liccnrcd taw (Chaptq 9. Commencing with Sction 7000 of Division 3 of thc Busines md Profsions Codc) or that he or shc is cxcmpt thqc,iom md the b8is for the allegcd cxcmption. Any violation 0f Sec{iolJo3l .5 by any applicantforap€flnitsubjetsthe applicanttoacivilpcmltyofnotmorcthillivchundrcddollus($500). -. _1. m ownq of the property. or my cmployG with wag6 I thcir slc compensalion, will do the wort md lhc sttuclre b not intaded or offdcd for sle (Sc.7044, Bwin6s ild Prcf6sions Code: Thc Contractor's Licosc Law do6 not .pply to il omq of thc pmpqly who huilds or improE thqo& od rvho do6 such wrlt himsclf or h6clf or thrcugh his or hc om cmploycc. providcd that such imp.ovmts @ not inloded oroflscd for slc. If. how6,6. lhe hrilding or improvmt is sld withh one )er ofcomplction, thc Ownq Buikk will haw thc htrdm ofprovinS thd he or stre did not tuiH or imForc thc pmpqry ftr thc Ftrpo$ of slc). _1. as owner of the propedy. am exclusively contracting with licensed contractors to construct the project (Sec. 7M4. Business builds or improves thereon,and I'>rofession Code: The Contractor's License Law to an owner of property who and who contracts for such projects pursuant to the Contractor's License Law). \ _l arn exempt under floto. I hereby afTinn under penalty of of the _l have and will maintain a Certifrcate of Consent to Self-lnsure for workers' compensation, as provided for by Section 3700 of the Labor Code. for the performance of the work for which the pcrmil b issued. _l have and will maintain workers' comp€nsation insurance. as required by Section 3700 of the l-abor Code. for the performance of the work for rvhich this p,ermit is issued. My workers' compensation insurance carrier and policy numhr are: Policy Number: ExPires: _l certi$ that in the performance of the work for which this pcrmit is issued. I shall not employ any person in any manner so as to become subject to the workers'and agree that if I should become subject to the $'orkers' compensation provisions I shall. forthrvith cotnply rvith those provisions. WARNING: Failurc to secure civil frnes up to one hundred unlawful. and shall subject an anployer to criminal penalties and to the cost of compensation. damages as provided for the Section .1076 of the Labor Code. 9 (cornmencing w'ith Section 7000) of Division -3I hereby a(firnt under penalty of perjury that of the Business and Professions Code. and my liceme is in full force and effect. License Class: License Number: l)irlt'. ('ttltlt':tclor CONSTRUCI'ION LENDTNG AGENCY I hreby afffm undq p6ahy of perjury that thoc is a comtruction lmding agocy for thc perfommcc of thc work for which this pamh b issued (Sec. 3097, Civ. C.). lrnder's Name:I I-ender's Address: APPLICANT DECLARATION I herebry affrrm under penalty of perjury one of the following declarations: Demolition Permits-Asbestos Notif-rcation Federal Regulations (Title 40. Pan6) -Required Lctter of Notification t I ccrrify that the regulations regarding asbestos reinoval are not applicable to this project. I the above infonnation ordinances hereby authorize above mentioned Applicant or Pernrilec I havc (94<$/^/tP I thc Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/Ve nU I n s u latio n Roof Sheathinq Shear Wall I t Framinq n ,1 -l -?o Dfi+YN lnsulation/Energy )c'/ ld t 2)\>ft*?? Drywa[-tc 2, I Dt+.+7 Ext ltn/tath ln /A)D*#-y Brofrf,n Coat Masonry Pool Fence T-Bar Handicap Req. Deputy Final Report Enqineer Final Report Flood Zone Certif. FINAL It tv 1r Dt{rv 7 Certificate of Occu pancy Notes. Remarks, Etc. ( 'lttle t I I