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BUILD!NG. INSPECTOR RECORD <br />SITE.WORK DATE !D/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I h6eby amrm undq pcnalty of pcrjury that I m exempt from thc Contracton' Licw Law for thc following rcmn (5(.7031.1 <br />Busins roxt Profsion Codc): Any City or County which requirc a pc[mh to construc{. alta. improvc &rnolish or repair my <br />structure. Jrior to its iswce. abo requir6 thc applicmt for such pfimit to filc a signcd statmot that h€ or shc b licq&d p$uet <br />to thc previsioN of thc Cotrtractor's Licmsql Law (Chaptq 9. Commcncing s'ith Sstion 7000 of Division 3 of thc Busins md <br />Prefe$ions Code) or that hc or shc is cxcmpt thqcfrom ild thc basis for the allcged cxmption. Any violation of Sdion 7031.5 by uf <br />applicantforapmnitsubjetsthc applicanttoacivilpenaltyofnotmorethilfivchun&cddollils($500). <br />[y'gs o*no of f hc property. or my emplo]c with wag6 I their sle mmpflsation. will do the work ild the structrc b not <br />-mr*f,ql or offcrcd for ele (Se.7044. Rusine ud Prcf*ioG Codc:'Ihc Contractor's f.icffic lrw do6 not apply to d owns of <br />thc properiy who builds or imlrcvc th6@tr md who do6 such rrcrk himself or hffielf or thrcugh his or he own cmployc. <br />providcd rhat such imfrov@sts e mt iiladcd or offacd for sle. lf. howos. lhc building or improvmdt is eld wilhin onc yw <br />ofcomphion. the Owna Buildq will have thc burdar ofproving thd he or she did rct build or impovt the prupory for thc purPos of <br />sle). <br />___ l, r ounr ofthe propqty. m exclusivcly contractirS with licfiscd contraclo6 lo coGtrucl th€ proj€:t (Ss. 7M4. Buins <br />and ProfasionCodc:TheContractor'sLiccnscLawdo6notapplyloroorvnoofpropcnywhobuildsorimprovcsth6@n. <br />and rvho conlmcls for such projsls whh 8 Contmclo(s) licffed puNuot lo lhc Contractor's Licme Lsw). <br />_l arn exempt under Section-,lbr this <br />o^r",' ///t?/l?()rnlrcr: X <br />I hereby affirm under penalty of po'jury one of the <br />_l have and rvilt maintain a Cerrifrcate of Consent to Self-lnsure for \r'orkers' compensation. as providd for by Section -3700 of the <br />Labor Code. for the performance of the work for rvhich the perrnit is issued. <br />_l have and rvill maintain workem' compensation insurance. as required by Section 3700 of the Labor Code. for the perfonnance of <br />the work for rvhich this permit is issued. My workers' compensation insurance carier and policy number are: <br />Can'ier:- <br />-Policy Number:-Iixpires: <br />-):l,cnify that in the pqforrmncc of the $,ork for which this Imit is isstrcd. I shall not mploy any pcrmn in any mmno <br />-s 6 to becomc subjet to thc wortffi' compcnmtion la*s of Califomia. and 8grc that if I should bcomc subjct to thc <br />sorts' cornpcnstion provisioro ofSccrion 3700 ofthe labor Code I shall. fonhrvith comply with thorc prcvisioro. <br />WARNING: Failurc to wue rvork6' comJEnsation mvmge is unlarvful. md shall subjccl o mployu to siminal fmlties od <br />civil fines up to one hundred thousand dollars ($100.000). in lhe cost of compensation. damages as provided for the <br />attorney's fees. <br />r< <br />9 (commencing rvith Section 7000) of frivision 3I hereby alTirrn under penalty of perjury that I zun pro\,ision of <br />of the Business and Professions Code. and my license is in full force and effect. <br />License Class:-License Nurnber: <br />Contrnctor:l)atc: <br />CONSTRUCTION LENDING AGDNCY <br />I hercby aflirm unde penalty ofpmjury that thce is a coNtruction lf,ding aSency for the pqfonnmce ofthe rvork for which this ponit is <br />issued (Ss. 3097. Civ. C.). <br />[.entlcr's Naltte: <br />l.ender's Address: <br />APPLICANT DEC LARATION <br />I herelry allirm under penalty of perjury one of the following declarations: <br />Denrolition Pennits-Asbestos Notification Fedcral Regulations (Title 40. Parl6) <br />---Required Letter of Notification <br />__l corify that the federalregulations regarding asbestos rerno!'alate nol applicable to this project. <br />state that the above <br />the <br />above rnentioned property for inspection <br />f,AbD,*,-/{'t;// rApplicnnt or Agenl Signature' * <br />I'errrrilcc nanrc (llrinl): ' <br />and <br />bo-^ Q ' <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bfloor/Ve nUl n s u lation ,I 'A rt.z= <br />Roof Sheathinq tItvltet Lhrld,'t168 <br />Shear Wall <br />Framinq <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonrv <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />I ,l /)/)M) <br />FINAL llll't ll7 /lt/,01411 au/r\%/ <br />Certificate of Occupancy I t <br />Notes, Remarks, Etc. <br />--+