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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS 0\\'NF,R Ilt rIl,l)1..R l)F.1,(',tRA'l l()N <br />I hseby affirm unds p€nalty of pqjury that I m exmpt frem the ContracloE' Licarc lrw for thc following rcen (56.70-11.5- <br />Buinss and Profsion Code): Any City or County which rcquira a pannit to construct. altc. improvc dcmolish or rcpair my <br />structuq prior to its issumcq also requir6 the applicmt for such lmit to file a signed stdmot that he or she b licqscd pmuilt <br />to thc prcvisions of the Contractor's Licenred Larv (Chapter 9. Commencing with Setion 7000 of Division 3 of the Busines md <br />Prefe$ionsCodelorthathcorsheiscxcmptthGefromedthebasisfortheallegedexemption. AoyviolationofSdionT03l.5byany <br />applicantforapmitsubjctsthe applicsnttoacivilpenaltyofnotmorethmfivehundrcddollm($500). ' <br />_1. as owner of the Fnoperty. or my employers with rvages as their sole compensation. rvilldo the rvork and the structure is not <br />intended or offered for sale (Sec.7044. Business and hofessions Code: 'I'he Contraclor's [-icense [.aw does not apply to an o\lner of <br />the property rvho builds or irnproves therqrn. and who does such wort himself or herself or through his or her own employees. <br />provided that such irnprovonents are not intended or offerd for sale. tf, however. the building or itnprovement is sold within one year <br />of completion. the Orvner Builder rvill have the burden of proving that he or she did not build or irnprove the propoty for the purpose o[ <br />sale). <br />-1. <br />as owner of the property. am exclusively contracting rvith licensed contractors to constnrct the project (Sec. 7044. Buiness <br />and [tofession Code: I'he Contractor's License Lau'does not apply to an owner of property rvho builds or improves thereon. <br />and rvho contracts for such projects rvith a Contracto(s) licensed pursuant to the Contractor's License Larv). <br />-l <br />am exempt under Section-. B. & P.C. for this reason. <br />Date: Owner: <br />WORKF'RS' CONI PENSATION <br />DECLARATION <br />I hereby affrnn under penalty of perjury one of the follow'ing declarations: <br />_l have and rvill maintain a Certificate of Consent to Self-lnsure for rvorkers' compensation. as provided for by Section 3700 of the <br />Labor Code. for the perfionnance of the rvork for rvhich the petmit is issued. <br />-l <br />have and rvill rnaintain workers' cotnpensation insurance. as by Section 3700 of the Labor Code. for the performance of <br />the rvork for is workers'carrier and plicy number are: <br />.D <br />Policy *rrb"r, - ClO Lf t t_.a <br />Exoires:z/z r, <br />_l ceflify that in the performance of the rvork fiur rvhich this perrnit is issued. I shall not employ any person in any manner <br />so asto bec1rme subject to the workers'cornpensation larvs of California. and agree that if I should becorne subject to the <br />rvorkef,s' compensation provisions of Se'ction .1700 of the Labor Code. I shall. forrhrvith cornply rvith those provisions. <br />WARNTNG: [;ailure to s€cure ttorkers' <br />civil fines up lo one hundred thousand <br />compensation coverage is unlas'ful. and shall subject an onployer to criminal penalties and <br />compensation. damages as provided for thedollarsincost of <br />Section -1076 of the Code. interest and attorney's <br />/ <br />DECT.ARATION <br />I hereby affirm un<ler penalty of perjury that t arn licensed under provision of Chapter 9 (cornmencing with Section 7000) of Qivision 3 <br />of the Business and Professions Code. and my license is in full force and effect. o <br />License Class: I <br />,rnu)l[ffi <br />a <br />Number: <br />W <br />I hrcby affim unda pcnalty of pcrjury that th@ is 8 construc(ion lcnding agocy for thc pcfomcc of thc work for which this pqmit b <br />issued (Se. 3097, Civ. C.). <br />Lender's Name: _ <br />Lender's Address: <br />APPLTCANT DECLARATION <br />I h6dry allinn under penalty of perjury onc of the following declarations: <br />Dernolition Perrnits-Asbestos Notification Federal Regulations (Title 40. Part6) <br />-Required <br />Letter of Notification <br />colify that thc federalregulations regzu'ding asbestos rcrnovalare not applicable to this project. <br />certi$/ that I have read and state that the ahrve inflormation is correct. I agree to cornply rvith all City and County <br />ordinances and Slate l-au's building and hereby authorize represextatives of this City and County to enter upon the <br />above mentioned property for <br />Ap;llicarrt or Agcrtt <br />l'ernritee nunre (grrirrt): F AAf h-( O ,Ly-- orr"rl'ftn(q <br />Set Backs <br />Forms/Steel/Holdowns <br />Ereqtion Pdds <br />UFER Ground <br />SLAB FIoor <br />Su bfloor/VenUI nsu lation I ^/l ^A <br />Roof Sheathing ////1/q /(Wtecz vaw <br />Shear Wall I <br />Framing <br />Insulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputv Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />A <br />f.^,,(.r. nA <br />FINAL ///lv/{4 /-rutz /cv_q <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />&7Lfr