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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS owNER lltJ I l.l)l:R DEL('AR,\ l'lON <br />I hqeby afftrm unde penalty of perjury that I m qempt from thc Contracto6' Licme Law for the fotlowing rcffin (Sc.70-l1..5 <br />Busines and Profeion Codc): Any City or County which rcquirs a p6mit lo coNtrucl, altr. improve, donolish or rcpair any <br />structue, prior to its isuuce. also rcquirG thc applicat for such pennil to file a signed statmot lhat he or dle is licmred ptmust <br />to the provisiore of the Contractor's Liccnscd Lrw (Chapt6 9, Commmcing with Sction 7000 of Division 3 of the Busins od . <br />PrcfsionsCode)orthathcorshciscxmptthrcfromildthebosisforthcallcgcdexmpion. Anyviolariof,ofSdionT03l.5byany <br />applicant for a pmit subjGts thc applicant to a civil pmlty of not more thd five hundrcd dollus ($500). <br />_1. 6 owner of thc propsty. or my mployc with wag6 6 their elc compwlion. will do thc work aad the structrc is not <br />inrqrdcd or offscd foi elc (SG.?044. Buine md kofruiom Codq The Contractor's Licosc law dos not apply lo m oms of . <br />thc Eop.fly who builds or improvs tlson. od who doc such \ror* himsclf or hfficlf or thrcugh his or htr om cmploy6. <br />provided that such improvoots rc not iltodcd or off<cd for slc. tf. ho16'q. the boilding or imJrovmt is mld u'hhin onc ya <br />of complaion. thc Ormo Buildq will havc rhc budfl ofprcving that he or she did mt build or improvc thc ptopqly for thc purposof <br />ele). <br />_1. cowns of the propsly. m exclNivcly contractinE with licmsd contmctoElo coNtrucr lhc prajet (Se. 7044. Bsios <br />ed Prof6sion Code: Thc Contmctor's Liccnsc Law do6 not apply to u o$nd ofpropcny who builds or improl'6 thq@n. <br />and who contmcts for such trojds with I Contraclo(s) licscd pmwt to the contraclor's Lic6c I2w). <br />-l <br />an excmpt under Section--. B. & P.C. for this reason. <br />Date:_Owner:_ <br />WORKERS' COI}IPENSATION <br />DECLARATION <br />I hereby afftrm under penalty of perjury one of the following declarations: <br />_l have and rvill maintain a Certificate of Consent to Self-lnsurc for workers' compensation. as provided for by Section 3700 of thc <br />l-abor Code. for the perfonnance of the work for which the p,ennit is issued. <br />_l have and will maintain workers' compensation insurance, as requird by Section 3700 of the Labor Code, for <br />the work for rvhich this permit is issued. My w,orkers' compensation insurance catrier and policy numkr are: <br />S., eq/ c \-( N o-\roq- [(a11igr. \-,- --. ' \E--:-- trtr.,-policy Nr,,.uu, SLI C \t'q Etq Expres: : <br />the performance of <br />_l ccnify that in the perforrnance of the rvork for which this permit is issued. I shall not employ any person in any manner <br />so as to become subject to the workers' compensation laws of California. and agree that if I should becotne subject to the . <br />rvorkers' compensation provisions of Section -3700 of the Labor Code. I shall. forrhn'ith cornply rvith those provisions. <br />WARNING: Failure to sccure $,orkers' compensation coverag,e is unlarvful. and shall subject an onployer to crirninal penalties and <br />civil fines up to one hundred thousand dollars ($100.000). in addition to the cost of compensation. damagcs as provided for the <br />Section -3076 of the Labor Code. interest and attorney's ,\ <br />I hereby alTirm under penalty of perjury that I am licensed under provision u'ith Section 7000) of Division 3 <br />of the Business and Professions Code. and my license is in full force and <br />License Ct"rr, ( <br />,rr", t'W <br />IC)379\ <br />(rontracto',J4 <br />I hereby affirnr under penalty of perjury that there is a conslruction lending agency perfonnance of the rvork for rvhich this pennit is <br />issued (Sec. 3097. Civ. C.). <br />Lender's Name: <br />API!,ICANI.DECT.ABAIIAN <br />I hqlby affim unds pcnahy of pajury onc of thc following dslsrations: <br />D@olition Pqmit$Asb6tos Notificstion Fcdcal Rcgulations (Titlc 40' Part6) <br />-Requircd <br />L€tts of Notificarion <br />m.l cqtify that the fcdaal regulatiom rcgrding rbstos rmovsl ue not applicablc lo this pmjcd. <br />_l cGtify thst I havc rad this application ud statc that the abovc infomation is colrcl. I agrc to comply with all City md County <br />ordir"n"o'-d Strt. t * rchting io building construclion, md hqcby authorizc reprefltalive of this City sd County to 6tq upon thc <br />above mentioned propetty ftlr inspection <br />,r,., tt/tApplicant or Agent Signature: <br />Permitec nrme (print):_L vrSlo\\-t rd^J <br />l,q <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bfloor/VenUl n s u lation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Energy <br />Drnruall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonrv <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif. <br />FINAL l\tk.?//D4r'O(T-H6J1 <br />Certificate of Occupancy t <br />Notes, Remarks, Etc. <br />Lender's Adclress: <br />{