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BU!LDING. INSPECTOR RECORD SITE.WORK DATE ID/S!G.COMMENTS OWNER BUILDER DELCARATION I hcefu a{finn und6 penahy of pqjury lhat I m exempt from lhc Contractom' Licrcc taw for thc following rcun (54.7031.5 BNin6s ild Profeion Codc): Any City or County which rcquirs a pcrnit to consiruct, altq. improvq danolish or rcpair my 3trucluq prior to its issumce. also rcquirc the applicat for such pennit lo file a signcd statmat lhar hâ‚¬ or shc b licensed plmmt to the pmvisiom of the Contractor's Liccnscd taw (Chapts 9. Commcncing with Sction 7000 of Division 3 of the Busine mr! Prcf*sionsCode)orthathcorshciscxcmptthqcfromadthe bcisforthcallcgedcxmption. AoyviolationofSstionT0ll.5byany applicanl for a pmit subjcts lhc applicant to a civil penalty of not morc thil fivc hundrcd dollss ($500). i l. as owner of the pro5rerly. or my etnployees with rvages as their sole compensation. rvill do the rvork and the stnrcture is not intencled or offered for sale (Sec.7M4. l]usiness and Professions Cotle: 'fhe Contractor's License Larv does not apply to an owner of the propoly rvho builds or improves thereon. ard who does such u'ork hinrself or herself or through his or her own employees. providecl that such improvonents iu'e not intended or offerd for sale. lf. horvwer. the building or improvclnent is solcl rvithin one y'eiu of cornplaion. the Orvner Builder will have the burden of proving that he or she did not build or irnprove the prcrpo'ty for the purpose of sale). I _ _ l. as o\\,ner of the properly. iull exclusively contracting u'ith liccnsed contractors lo construct the project (Sec. 7044. Business and Professkrn Code: 'l'he Contractor's l-icense Larv does not apply to an owner of property who builds or itnproves thereon. and rvho contracts for such projects rvith a Contracto(s) licensed pursuant to the Contractor's License Larv). I arn cxenrpt under Sectiort -, B. & P.C. for this reason. l)nte:( )rr ncr' WORKER,S' CONTPENSATION DECLARATION I hereby alTinn under penalty of po'jury one of the follorving declarations: __ _t have and will maintain a Certificate of Consent to Self-lnsure for workers' compensation. as provided for by Section 3700 of the Labor Code. for the performance of the work for which the perrnit is issued. _l have and will maintain workers' compensation insurance. as required by Section 3700 of the Labor Code. for the perfolmance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: ('irr t ict : Policv Number:_Expires: __l ceatiry that in the perfonnancc ofthe work for which this pcamit is issucd. I shall not mploy any pctson in any muna rc stobecomesubjctlothcwo*6'compqvtionlasofcalifomia.andagrclhatiflshouldbccomcsubjsttothc \rork6' cotnpostion prcvisions of Sation 3700 of the Labor Codc. I shall, fonhwith comPly with thos provisioru. WARNING: Failure to suc sorkc'compeMtion covmge is unlasful. and shall subjct o anploycr to simhd pQahi6 ud civil fina up to one hundrci thoMd dollm ($100,000). in addirion to lhe cost of compcmation, dmagcs c providcd for lhc ' Section 3076 of the Labor Code, interest and attorney's fees. D"r., tUf2/l(1 l)li(' 1.,\ ll,\'l' !( )N I here[y aflinn under penalty of perjury that I arn licensed under provision of Chapter 9 (cornmencing with Section 7000) of Division .1 of the Business and Professions Code. and rny license is in full force and effect. I.icense Ctass, 6 u"t., ll ll2/ll ('oNS'l'lr[J("1'loN l. lrN l) I N(; A(; liN(']' I hdEbyamnnunderpenaltycf perjurylhal thqcisacoNtruction lcndingag@cy forthepqfommce ofthework forwhichthispermit is issued (Sec. 3097, Civ. C.). Lender's Name: I-ender's Address: APPI,ICANT DECLAR/I'IION I hereby allinn under penalty of perjury one of the follorving declarations: Dcrnolition Permits-Asbestos Notification Federal Regulations ('l'itle 40. Pan6) - -Required Letter of Notification I certify that the federal regulations regarding ashtos removal are not applicable to this project. I cdify that I have rad this applicatien md state that the abovc infomration is corecl. I agre to comply lvith 8ll Cily and Counly ordinancG and State [arvs rclating to building costruclion. atrd h6cby aulhorize relrestalivs of this Cily md County to @tq upon lhc above mentioned property for inspection Applicrrnf or Agerrt SignntrrreI Perrrrifee n$nre (print): -- #r' I )irlc 4mt|t(' ilttz/0 Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloor/Ve nul n s u !atio n Roof Sheathing t( ltct ltq v*tY)6L fr(1 Shear Wall U Framinq , lnsulation/Energy il/la/1 f V4--tfi/).rr-*trl Drywall ,t Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif I FINAL ttl04ta I2A nn 61 .#67 Certificate of Occupancy I ll Notes, Remarks, Etc. I ,