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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG COMMENTS O\\'N l1R llU I l.l)l:lt l)Irl.(',,\RA'l'ION I h@by affim unda pcralty of pcrjury that I m cxcmpt from thc Contracton' Licro lrw for thc following rcmn (Se.7031.5 -Busins md hofsion Codc): Any City or County which rcquirs a pannit to construcl. altq, imprcvq danolish or rcpair my t structuc. prior to its isuacc. also rcquLs thc applicul for such Imit to filc I signed statm@t that hc or shc b licasâ‚¬d pmwt to thc provisioro of lhc Contractor's Licmsed Law (Chapto 9. Commcncing with Setion 7000 of Division 3 of thc BBinN md Prcfsions Codc) or that hG or she b ermpt thftfrom 4d thc basis for thc allcgcd qmption. Any violrtion of Sstion 7031.5 by aoy applicantforapcrmitsubjâ‚¬lsthe applicmttoacivilpcnsltyofnotmorcthefivehundrcddolltrs($500). _1. c omq of thc propsrty. or my mploye with wage o thcir slc compwtion, will do thc work srd thc stnrluc b not intoded or offqrd for slc (Se.7044, Buinas ud Profsioc Codc: Thc Contractor's Licffc l3w do6 not apply to o om6 of thc propqry who builds or improve thsorl' 8nd who do6 such rcrt himsclf or hfficlf or lhrcugh his or ha om cmployce, provided that such imprcvmdts e rct intadcd or offscd for slc. l[ how. thc tuilding or imprcvmt is old within onc ]qr ofcompbtioo thc Ownq Buildq will have thc hrdsr ofpoving that hc or she dil rct build or imprcw the prcpqly for thc prpore of sk). _1. cownoof thc prcpcrty. m erctusively contracting with licoscd contracloEto coNtruct thc projet (Sd. 7044. Bsine md PEf6sbn Codc: Thc Contractor's Licosc Law doc not apply lo o owno of prcpoty who builds or improv6 thq@n. and who contncts for such projers with a Contncto(s) licscd puEwt lo thc Contractor's Liccffi lrw). -l am exempt under Section B. & P.C. for this reason. l)irtc ()rr nt'r: WORKERS' COI}IPENSATION DECLARATION I hereby affrrm under penalty of perjury one of the follow'ing declarations: _l have and will maintain a Certificate of Consent to Self-lnsure for workers' compensation, as provided for by Section 3700 of the Labor Code. for the ptrforrnance of the work for which thc pennit is issued. _l have and rvill maintain workers' compensation insurance. as required by Section 3700 of the l.abor Code. for the performance of the work for which this permit is issued. My workers' compcrsation insurance carier and policy numtler are:Fuw -l that in the perforrnance of the u'ork for which this permit is issued. I shall not ernploy any person in any manner should bccome subject to the _l certify to the workers'compensation la$'s of California. and agree that if Iso as to kome subject provisions of Section 3700 of the Labor Code. I shall. forthrvith comply rvith those provisions.rvorkers' compensation peflalties andWARNING: Failure to secure workers' compensation coverage is unlawful.an cmployer to crirninal civil fines up to one hundred thousand dollars ($100.000). in addition as provided for the Section 3076 Code. interest and attomey's fees. I hereby aflirm under penalty of perjury that I am licensed under provision of Chapter 9 (cornmancing with Section 7000) of Division 3 of the Business and Professions Code. and my license is in full force and effect. License Class:Nurnber: (lontractor:f7 ,LLa/,Jo /futF fi4 LT_'/ CONS'IRUCTION LT:NDING ACENCY I hwby amnr under pcf,alty of p(jury that th6c is a onstruction loding sgocy for the pqfonnmce of thc work for which this pqmit is issucd (Se. -1097, Civ. C.). Lender's Narne: lrnder's Ad&ess: APPLICANT DECLARATION I hereb), affinn under penalty of perjury one of the follorving declarations: Demolition Permits-Asbestos Notification Federal Regulations (Title 40. Part6) -Required Lctter of Notificalion _l cerriD that thc federal regulations regarding asbestos removal are not applicable to this project. -l cerri$, that I have read this application and is correct. I agree to with all City and County and County to entâ‚¬r upon theordinances and Stale Laws relating to rnent ioned property for inspection or Agertt I)ate: Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloor/Ve nUl n su Iatio n Roof Sheathing Shear Wall Framinq lnsulation/Enerqy Drnryall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputv Fanal Report Enqineer Final Report I Flood Zone Certif tt , FINAL / Llflrq E [z1f/Lt tq Certificate Notes, Remarks, Etc. r \ \ {-.**:- (*",,., Number: Date:-1/Lh* Permitee name (print):6 f C t O,. /t