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BUILDING- INSPECTOR RECORD SITE.WORK DATE ID/S!G.COMMENTS OWNER BUILDER DELCARATION I hceby atfim unda pcnalty of perjury that I m cxcmpt from thc Coriltaclom' Licmc Law for thc following rcon (54.7031.5 Busines md Profsion Codc): Any City or County which requirc a pemit to coGtruct. 8ltq. imprcvc, dernolish or repair my struclue. prior to its isumce. also rcquire thc applicut for such pcmit to file a signed statmf,t that he or shc is liceNcd pffiuflt to the provisions of thâ‚¬ ContEctor's Liccnrcd Law (Chapts 9, Commencing with Setion 7000 of Division 3 of the Busins ud Prefe$ions Code) or that hc or shc is exmpt thocfrom ild thc basis for the allcged exmpion. Any violation of Sction 7031.5 by 8ny applicantforapmitsubjctsthc applicanttoacivilpcnaltyofnotmorcthefivchundreddollus($500). -1. 6 oqq ofthc propory. or my mploye with wag6 6 thcir mle mmpemtion. rvill do thc wort md the stnrtm b mt t into,aoa o. ofisea foi sb (4c.7044, Bsins ild ProfsioN Codq Thc Conlractor's Licffi Law do6 not apply to an 0$!6 of the propcfly who builds or improc thon. ard who doe such rcr* himself or hmelf or thrcugh his or ha om cmploye. providc<l that such irnprovmot3 e not intoded or ofldcd for gle. tf. howd6. the hrilding or imprcvqtrot is $ld within one )qr ofcomplaion. the Owre Buikk will have rhe hrdo ofproving thar he or she did not build or imprevc lhe plopsly for thc putrt$ of mlc). _ l.sownqofthcprop6l).mcrclusivelycontractingrvithlicsdcontractoEtoconslruclthcproj*t(SE.7044.BGinN and PFf6sionCodc:;lheContractor'sLiccnscLarvdosnotapplytoflown6ofpropqlywhobuildsorimprovBth6@n. and who contmcts for such projeds with a Contracto(s) licqEâ‚¬d purs@t to the Contractor's Liccc t w). - I arrt cxentpl under Section B. & P.C. for this reason. l):t I c.On'ner: \\'o RK Iti{S; ('tri\ t Pl,N sl'l'10 N I)t(LAlt,\IlON I hseby aflim undq paaltyof po'juryonc ofthc follorving dclaatioro: _l have md will maintain I Ccrtificatc of CoBdt to Sclf-lNure for rrcrkm' comptuation, I trovidcd for by Sction 3700 of the Labor Codc. for the psfomuce of the wrt for which the pmh is isued. t'?avc and witt maintain workm' compcmation ircurancq s requfed by setion 37OO of thc labor Code. for thc pofommcc of ' thc u'ork for which this pclmir is isucd. My work6' composalion insurucc cuia ud policy numbd rc: ('an'icr:st f lvrSut-KanC*P Cs /' /.lsPolicy r.ru,r,uo, B [\ Lt IYK -Expires: + _l cerrify that in the perforrnance of the work for which this perrnit is issued. I shall not etnploy any person in any manner . so as to become subject to the workers' compensation tau's of California. and agree that if I should become subject to the \.r,orkers' compensation provisions of Section 3700 of the t,abor Code. I shall. forths'ith comply with lhose provisions. WARNING: Failure to sâ‚¬cure \\,orkers' compensation covef,age is unlaw'ful. and shall subject an onployer to criminal penalties and civil fines up to one hundred rhousand dollars ($100.000), in addition to the cost of cotnpensation. damages as provided for the attorney's fees. I hereby affrrnr under penalty of perjury that I arn licensed provision of ('hapter 9 (comtncncing s'ith Section 7000) of Division 3 of the Business and Professions Code. and my license is in full force and efFect. License ctass' C- ,rr.' 1/3, 1])_License a.-o-E+ a. I CONS'IRUCTION LENDING AGENCY I hereby amrm undq penalty ofpojury that thoe is a construction lmding agocy for the perfonnance ofthe work for rvhich this permil is issued (Sec. 3097, Civ. C.). Lendcr's Narne: Lender's Address: APPLICANT DECLARA'I'ION I hereby aflinn under penalty of perjury one of the follorving declarations: Dernotition Perrnits-Asbestos Notification Federal Regulations (Title 40. Pan6) --Required Letter of Notification I certify that the lderalregulations regarding asbestos removalare nol applicable to this project. -l ccrrify thar I have read this application and state that the above infltrnnation is correct. I agrer to cornply rvith all City and County thcordinanccs and State l.arvs relaling to building and representatives of this City and County to entcr upon above rnentioned propetly for Applica:tt or Agent Permitee name (print): ---- -BL g- Hrrt t".'-l - r,",",--l t(slo+" Set Backs -A- - Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor I S u bfloor/Ve nUl ns u latio n l^.A Lt ^/ Roof Sheathing I -t wru wtqfiy }A Shear Wall I Framing lnsulation/Enerqy Drywall Ext./lnt. Lath Brown Coat [\4asonry Pool Fence T-Bar Handicap Req. Deputv Final Report Enqineer Final Report Flood Zone Certif. ,fD / 1,,, ^ffif-o-l - l-/-21-ZO 2c 2rl FINAL Z-f -zo?-a /Lct?,Je @> RD Certificate of Occu pancy Notes, Remarks. Etc a