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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS O\1'N [.R l]t I I l,l)l:lt l)ltl.('A RA'tlON I hseby allinn unds penalty of pdjury that I m ercmpt from thc Contmclon' Licme law for thc following remn (Sc.70-11.5 Busincs and Prof6sion Codc): Any City or County which rcquira a pcmit to coEiruct. alta. improta danolish or rtpair my. struclurc. prior to its isswcc, also rcquirs thc eplicet for such pemit to file a signed statmot that hc or dlc is licffed pummt to the provisions of thâ‚¬ Contmctor's Liccnsed taw (Chapts 9. Commocing with Sction 700O of Division 3 of the Buin* md ProfsionsCode)orthatlEorsheiscxmflthccfromudlhcb6sisforthcallegcdexmptioo. AnyviolalionofSationT03l.5byat applicant for a pcrmit subjcts the applicant to a civil pmlty of not morc thil five hundrel dollffi ($500). _1. c orvnq of the prcFny. or my employâ‚¬ with wag6 a their olc compewtion. will do thcwork md thc stnr1rc is not intqdâ‚¬d or offscd for ulc (Sc.7044. Businm ud Prcfxiom Codc: ThG Contractor's Licdsc lrw do6 not apply to an omq of the prepâ‚¬rty who buildr or imprcE thq@tr and who do6 such wd< himsclf or hcmlf or thrcugh his or ho own mploym. providcd that such improvqmts rc rct inodod or ofTqed for slc. lf. horvd6. thâ‚¬ boiHing or improvorcnt is mld within onc )ar ;fcompletion. the Owno Buildg will havc thc hrd6! ofproving tha hc or dre did rct build or imprcvc thc propqry for tlrc purpos of elc). _ I. 6ownd of the propo'ty. an crclusivelycontncting wilh licqBd conlmcloG lo @nslrucl thc projed (36. 7044. BEins and Profssion Code: The Contractor's Liccmc Law do6 not spply lo m orvne ofproperty who builds or improvs thq@n. and who contracts for such prcjcls wilh a ContEcto(s) licoscd punmt to lhe Contraclor's Licorc Law). I am exernpt under Section-. B. & P.C. for this reason. l)nlr:( )rr ner: I hereby affrrm under penalty of perjury one of the follorving declarations: _t have and will maintain a Cerlificate of Consent to Self-lnsure for workers' compensation. as provided for by Section 3700 of the Labor Code. for the pei'formance of the work for rvhich the permit is issued. _ I have and rvill maintain workers' cotnpensation insurance. as required by Section -i700 of the Labor Code, for the performancc of the work for which this pennit is issued. My workers' compensation insurance calrier and policy number are: .r*,.,, S{r< \-e t;r,^.-\ r I Poricy*,,u*, [1-?-? 6?-1 Expires::-@ _l cerrify that in the performance of the work for which this perrnit is issued. I shall not employ any person in any manner so as to become subject to the n'orkers'compensation laws of California. and agree that if I should become subject to the n,orkers' compensation provisions of Section -3700 of the Labor Code. I shall. forthrvilh comply rvith thosc provisions. WARNING: Failure to sccure rvorkcrs' compensation coverag,e is unlarvfrrl. and shall subject an onployer to criminal penalties and civil fines up to one huntlred thousand dollars ($100.000). in addition to the cost of compensation. damages as provided for the Section 3076 of the Labor (lode. interest and attorney's fees. ,,,., t t \z--r \eo nov,inn DECLARATION I hereby affrrm under penalty of perjury that t am licensed under provision of Chapter 9 (cornrnencing u'ith Section 7000) of Division 3 of the Business and Professions Code. and my license is in full ftrrce and effect. Licensc Nurnbcr:o '1 0 CONSTRUCTION LENDING ACENCY I hacby affirm undo penalty of pqjury thal thqc is a construction lending agmcy for the pofomce of the rvork for which this pflnil ls issued (Sec. -3097. Civ. C.). l-ender's Name: Lender's Address: APPLICA N'f DE(l LARJI"I'lON I herebyaffinnunder penalty of perjury one of the follorving declarations: Derno lit ion Perrnits-Asbestos Notifi cat ion Federal Regulat ions ('l'itle 40, Parr6) __- Required Letter of Notification -l cqtiry that the fedqal rcgulaliom rcgrding rbctos rmoval uc not applicablc to this prcjdt. I -hfcgri& rha I hrvc rdd this applic8tion ild state that the abovc itrfomation is cor6t. I agjeto @lnply wilh 8ll City md County qdinaocB ild Statc taws rchting io building construclioo, ild hqcby authoria rcpr6mtativ6 of this City ud County to olq upon thc above rnentioned property for inspection purposes. Allplicurt or Agenl Signattrrc: t,er,ircerir.re(prirrr): N \ C- L< ff\J \2YZ<.J S ,nre\, V-,\* Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/Ve nUl n su lati on Roof Sheathinq Shear Wa!! Framing lnsulation/Enerqy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputv Final Report Enqineer Final Report Flood Zone Certif. FINAL IZ tq q )ft thz tu+yt Certificate of Occupancy , Notes, Remarks, Etc. \\l)ale: \ \ -t-5 ('orrrractor: A)<^/^\s^ t a