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BUILDING- INSPECTOR RECORD SITE-WORK DATE ID/SIG.COMMENTS Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf Ioor/Vent/l nsu lation Roof Sheathinq Shear Wall , Framinq nl1s,lfu)Dl\nhr t#f,| !nsu lation/Enerqy I lr Drywall Ext./lnt. Lath Brown Coat [t/asonry Poo! Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif F!NAL zl t1ltp -F>*+*t I n-.VW Certificate of Occupancy I /I I NoJes, Remarks, Etc. I hereby affirm under penalty of JErjury that I m excmpt fmm thc Coilractom' Liccnrc Law for thc following rcason (Scc.703 1.5 Busincss ard Protbssion Codc): Any City or County which requircs a Jrcnnit to conslrucr. altcr, improvc, dcmlish or rcpair iiry structure, prior to its issuance. also rcquircs lhc applicant for such lrcrnrit to filc a signcd statcrrcnt lhal he or shc is liccnsd pursuant to thc prcvisions of thc Conracto('s Liccn*d ljw (Chaplcr 9. Commcnchrg with Scclion 7000 of Divi*i)n 3 of lrr,' Business srrd ProfcssionsCodc)orthathcorsheisexcmptthcrcfromandlhcbasisforlhcallcgcdcxcmFion. AnyviolationofscctirnTi3l.5byany applicant for a pcrmit subjccts thc applicant to a civil pcnalty of nol morc than five hundrcd dollds ($500). _1. as owncr of the ()r willdo thc work and thc structurc is not License Law does not apply to an owncr ofintcndcd or offcrcd frrr thc proprty who builds or and who docs such work hirnsclf or hersclf or through his or hcr own crnployces. providcd that such are not intcnded or offercd for salc. If. howcvcr. thc building or improvenrent is sold within onc ycar of cornpletion.Buildcr will have thc burden of proving that hc or shc did not build or inrprovc the propcrty for thc pur;nsc of sale). of the property. ant cxclusivcly contracting with liccnscd conlractors lo construct thc projcct (Scc. 7M4, Busincss and Pnlfcssion Codc: The Contractor's License Law docs not apply to an owt'rcr of property who builds or improves thcreon. and who contracts for such projects with a Contractor(s) licenscd pursuant to thc Corttractor's Liccnsc Law). -l arn cxcnrpt urrdcr B. & P.C. tbr this rcasotl. DI,l(:1.,\RA'l'l()N I hereby affirm undcr penalty of perjury one of thc dcclaratiotts: _l have and will maintain a Certificatc of Consent to Sclf-lnsurc lbr workers' compensation. as providcd for by Section 37fi) of the Labor Code, for the pcrformance of thc work tbr which the permit is issucd. _l have and will maintain workers' conrpensation insurancc. as rcquired by Sect ion 3700 of thc Labor Codc. for thc perf<lrnrance of thc work for which this permit is issued. My workers' compensation insurancc carrier and policy number arc: Policy certify that in the pcrformancc of thc work for which this perrnit is issucd. I shall not cnrpkry any pcrson in any tnanncr so become subjcct to thc workcrs'cornpensation laws of California. and agrec that if I should bccotne subjcct tothc workers' compensation provisions of Scction 37fi) of the Labor Code. I shall. lbrthwith comply with those provisiotts. WARNING: Failurc to secure workers' contpensation covcragc is unlawful. and shall subjcct an entployer to crinrinal pcnaltics and civil fincs up to onc hundrcd thousand dollars in addition to the cost of conrpcnsation.darnages as providcd for thc rScctiorr 3076 of thc Labor Code. intercst and l)ECLAlt,\'l'lON I hcreby atfirm under pcnalty of pcrjury I ant liccnscd undcr provision of Chaplcr 9 (conrnrcncing with Scction 7fiX)) of Division 3 of thc Business and Professions Codc. and my liccnsc is in l'ull fbrce artd elfect. Liccnse Class: Licensc Number: CONS'I'RI,]C'I'ION I,IiNDIN(; A(;IiNC}' I hcrcby afnrm undcr Fnaltyofperjury thot therc is a construction lcndirg agcncy for thc performncc ofthc work for which lhis Jrcnnil is issucd (Scc. 3097, Civ. C.). lrndcr's Name: lrnder's Address: APPLICANT DBCLARATION I hcrcby aflirnr undcr penalty of pcrjury ortc of thc lbllowing dcclarations: Dernolition Perrnits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40. Part6) Rcouircd Lettcr -I thc fcdcralrcgulations rcgarding asbcstos removal arc not applicablc to this projcct. ordinanccs with all City and County and County to entcr upon thc ab<lve Applicant or Pcrnrilee [or purposes. "",7 15 -2t'Z> I