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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hereby aflim undcr pqalty of pqjury that I m cxcmpt frcm lhc Contraclom' l.icos law for thc following rcmn (56.7031.5 <br />Ilusinss ad Profmion Codc): Any City or County which requirs a pemit to construct, alto, improvc. danolish or rcpair ay <br />structurc. prior to its issuuce. also rcquirc thc applicut for such pcrmil to file a siBncd statmfit that hc or she b licms€d pmuilt <br />to the prcvisions of lhe Contractor's l-iccnscd larv (('hapls 9. Commencing u ilh Sstion 7000 of Division I of thc Busines ild <br />Pmfesions Code) or that he or shc is dcmpt thqcfrom od the basis for thc alleged cxmption. Any violation of Setion 7031.5 by any <br />applicant for a pmit subjats thc applicant to a civil peoalty of not morc thil five hundred dollas ($500). <br />_ I. as owner of the property. or my employees with wages as their sole cornpensation. w'illdo the rvork and the struclure is not <br />intcnded or offered for sale (Sec.7044. Business and Professions Code: '[he Contraclor's l-icense l,aw'does nol apply to an orvner of <br />the properly s'ho builds or improves thermn. and s'ho does such work himself or herself or through his or her ou'n employees. <br />provided that such irnprovanents are nol intorded or offered for sale. lf. hon'ever. the tnrilding or funprovenrenl is sold s,ithin one )ear <br />the purpose ofof cornplaion. the C)r,vner Builder will have the hrden of proving tha he or she did not h,rild or improve the <br />sale). <br />l. as os,ncr of the property. arn exclusi\,ely contracling contractors to construct the project Business <br />theretrn.and ttof€ssion ('ode: 'l'he (-'ontraclor's License l-au' does an o\!'ner of property $'ho builds <br />and s'ho conlracts for such projects rvith a pursuant t() the conlractor's <br />I aln exernl-rt .c. rbr <br />t)ti( L.\R.\ Ito\ <br />I hereby alTirm undcr penalty of perjury one of the follorving declarations: <br />__l have and rvill maintain a Cerlilicate of Consent lo Self-lnsure for rvorkers' cornpensation. as provided for by Section 3700 of the <br />Labor Code. for the p€rfonnance of the work for rvhich the perrnit is issued. <br />- _l have and rvill rnaintain rvorkers' cornlrcnsation insurance. as required by Section -1700 of the Labor Code. for the performance of <br />the rvork for which this permit is issue<J. My rvorkcrs' compensation insurance carrier and policy number are: <br />I'olicy <br />-l <br />certi$, that in lhe performance of thc s'ork for which this issued. I shall nclt <br />and agree that ifl <br />ernploy any person in , <br />should become subject <br />any manner t <br />so as lo become subject to the workers' compensation larvs to the <br />\r,orkers' cornpcnsation <br />WARNING: I:ailure t<r <br />provisions of Section 3700 of the l-ahrr I shall. forrhrvith cornply rvith those provisions. <br />secure rvorkers' compensation coverage <br />thousand dollars ($100.000). in <br />and shall subject an to criminal <br />civil fines up to to compensation.a <br />Section -3076 Latxrr interest and attorney's fecs. <br />I hercby alTirm under penalty of pcrjury that I arn licensetl <br />of the Business and Professions Code. and my license is <br />DECLARAI'ION <br />under provision of Chaptcr 9 (commencing u'ith Section 7000) of Division 3 <br />in full force and effect. <br />l.icense _License Number: <br />Dete:_('ortl ractrlr: <br />CONSTRUC'IION LENDTNG ACENCY <br />I hcrcby affinn undo pcnahy of pqjury that th6e is a construction lending agocy for the Jufomance of the work for which lhis pomil is <br />issued (Se. 3097. Civ. C.). <br />Lender's Narne: <br />Lctttlct''s r\rltlt css. <br />APPLTCAN DECLARA ION <br />I herelry affirnr untler penalty of perjury one of the follorving declarations: <br />Demolition Pennits-Asbestos Notilication Federal Regulations ('titlc 40. Parl6) <br />--Required Lelter of Notification <br />-- I certify lhat lhe federal regulations asbestos rernol'al are not <br />I certify that I have read this application rvith all City and County <br />ordinances and State [-as's relating to to enter <br />above mentioned property for <br />I <br />A;lplicnrrt or Agcrtt <br />Iternritee nanle <br />state that the above infonnation is <br />and <br />/ <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bfloor/Ve nUl n su latio n <br />Roof Sheathins <br />Shear Wall <br />Framinq <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonrv <br />Pool Fence-[-Bar <br />]{andicap Req. <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif. <br />lt L' <br />FINAL tloltlwJL,,t !\Ylnb*P/-kd) <br />Certificate of Occupancy I <br />Notes, Remarks, Etc. <br />+On'ner: <br />[ixpircs: