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BU!LDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I haeby affirm undo penalty of perjury that I m excmpt from thc Contrsctors' License Law for thc followinS r@n (Se.7031.5 <br />Busin6s and Profsion Code): Any City or County which rcquirc a pcmil to @ngrud, altq. improv€, donolish or repair uy <br />structurc. prior to its isuocc, also requirs thc spplicmt for such pamit to file a signcd statmmt that he or dE b licoscd pmuut <br />to thc provisiore of thc Contractor's Licensed [:w (Chapt6 9. Comncncing with Setion 7000 of Division 3 of thc Busincs adr Profsions Codc) or that hc or slre is oempt thqefrom ud thc basis for the allcgcd cxmption. Any violation of Scrion ?031.5 by ey <br />applicmt for a pnnit subjets thc applicmt to a civil penalty ofnot more thil live hundrcd dollm ($500). <br />-1. <br />as owner ofthe property, or my employecs with rvages as their sole conrpensation. willdo the work and the stnrcture b not <br />intended or offered for sale (Sec.7M4. Business and Professions Code: The Contractor's Licensc Law does not apply to an owner of <br />the propo'ty who builds or improves theron. and who does such work himself or herself or through his or her own employees. <br />provided that such impovanrcnts are not intendod or offered for sale. l[, hower/er. the building or improvement is sold within one ]rzr <br />of complaion. the Ourner Buildcr will have the burden of proving thd he or she did not build or improve the propot'y for the purpose of <br />sale). <br />-f <br />, as owner of the property. arn exclusively contracting with licensed contractors to construct the project (Sec. 7U4, Buiness <br />and hofession Code: The Contractor's License Law does not apply to an orvner of property who builds or improves thereon, <br />and rvho contracts for such projects with a Contracto(s) licensed pursuant to the Conlractor's License Law). <br />-l <br />am exernpt under Section-. B. & P.C. for this reason. <br />Date: Owner: <br />WORKERS' COMPENSATION <br />DECLARATION <br />I hereby affinn under penalty of perjury one of the following declarations: <br />_l have and will maintain a Certificate of Consent to Self-lnsure for workers' conrpensation, as provided for by Section 3700 of the <br />Labor Code. for the performance of the work for which the permit is issued. <br />_l have and rvill maintain 3700 of the Labor Code. for the performance of <br />rvork for rvhich this and policy number are: <br />E,v tryc4^y <br />z t- ZotJ(o,,.,6ooo t zqtlr 1- <br />-l <br />cerrify that in the performance of the work for w'hich this perrnit is issued. I shall not onploy any person in any manner <br />so as to become subject to the rvork€rs'compensation laws of California and agree that if I should become subje<t to the <br />norkers' compensation provisions of SEction 3700 of the Labor Code. I shall. forthwith comply rvith those provisions. <br />WARNING: Failure to secure workers' compensation coverage <br />civil fines up to one hundred thousand dollars ($100.000). in <br />is unlawful. and shall subject an ernployer to criminal panalties and <br />the cost of compensation. damages as provided for the <br />Section -3076 of the Labor Code, interest and attorney's <br />I <br />DECI { RATION <br />I hereby aflirrn under penalty of perjury that I am licensed under provision of Chapter 9 (commencing with Section 7000) of Division 3 <br />of the lllusiness and Professions Code, and my license is in full force atd eflect. <br />\y'..*"C-Number:L5 <br />( <br />W <br />I hcreby affm undo p€nalty of perjury thar thac is a construcliotr knding agqcy for the pqfomce of the work for *'hich this pqnh b <br />isued (Se. 3097. Civ. C.). <br />Lender's Name: <br />Lender's Address: <br />APPLICANT NT'CI ^ RATION <br />I herety affrrm under penalty of perjury one of the follorving declarations: <br />Dernolition Perrnits-Asbestos Notification Federal Regulations (Title 40. Part6) <br />-Required <br />Letter of Notification <br />,r'cefli$/ that the federal regulations regarding asbestos removalare not applicable to this project. <br />is con'ect. I agree to cornply rvith all City and County <br />reprcsentatives of this City and County to entet' upon the <br />above mentioned prope(y fcrr <br />(ppli.",,t or Agent <br />,€Iermitee nnme 14 I )I <br />Set Backs <br />Forms/Steel/Holdowns -z/t-l <br />-lv--1 <br />Erection Pads 7'"/ry ',T.A-{U <br />UFER Ground <br />SLAB Floor <br />Su bfloor/VenUI n su lation <br />Roof Sheathinq <br />Shear Wa!! <br />Framing <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />,I <br />FINAL 3 /lo/aD <ry#ry-'.;n <br />Certificate of Occupancy 7 ru <br />Notes, Remarks, Etc. <br />x <br />\n,., (t \otl <br />8 <br />,