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BUILDING. INSPECTOR RECORD <br />S!TE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARAT]ON <br />I haeby aflirrn undo pcnalty of pcrjury that I m €xcmpt frem thc Contraclorc' l.icqrc Law for the following remn (5(.7031.5 <br />Busin6s ild Profsion Codc): Any City or County which requirs a pmit to coNlrucl. altc. improve. demolish or rcpair oy <br />structurc. prior to its isumcc. also rcquirs the +plicmt for such pcmit to filc a signcd statmot that h€ or shc b licascd puNmt <br />to thc provisiom of the Contractor's Liccnscd t:w (Chapts 9. CommcncinB with Setion 7000 of Division 3 of thc Busine$ md <br />Profsions Codc) or that hc or shc is ex€mpt thscfrom od thc basis for thc allcgcd crmFion. Any violation of Sdion 7031.5 by any <br />applicant for a ponit subjcts the applicanl lo . civil penalty of not morc lhm fivc huodrcd dollus ($500). <br />_1. o orms of thc propcrty. or my employe with wag6 6 thcir mlc compqrstion. rvill do the work dd thc structrc is nol <br />intoded or offqc{ for elc (36.7044. Bsins od Profsio$ Codc: The Contractor's Licsc tlw do6 not apply to il orvnq of <br />the tropqty rvho tuilds or irnprove thqan. md who do6 uch wort himsclf or hmelf or thrcugh his or ha orw mployrs. <br />providcd that such imprcmots uc not inrodcd or offqed for slc. lf. hoB'6, thc tuilding or imprcvmat b rld rvithin onc )q <br />ofcomplction. thc Owns Buil{a will have thc hrda ofproving thd hc or shc did rct build or improvc the plopqry for the purpo$of <br />ele). <br />_1. asowno of thc pop6ty. m exclusivcly contracting with licensed contraclos lo conslruct thc projct (Sc. 7044. Busin* <br />ild Profission Code: 'thc Contractor's Liccnsc Law do6 not apply to an orvnq ofpropcrty who builds or improvcs theron. <br />and who contmcts for such Fojecrs with a Contmcto(s) licffied pu6uant to lhc (bntractor's Licw law). <br />-l <br />am exempt under Section-. B. & P.C. for this reason. <br />Dnte: Owner:- <br />WORKERS' CONT PENSA'TION <br />DECLARA'I'ION <br />I hereby affirm under penalty of perjury one of the following declarations: <br />_l have and rvill maintain a Certilicate of Consent to Self-lnsure for workers' compensation. as Fovided for by Section 3700 of the <br />Labor Code. for the p€rfonnance of the work for which the pennit is issued. <br />_l have and witl maintain workers' compensation insurance. as requird by Section 3700 of the Labor Code. for the po'fonnancc of <br />the work for which this pennit is issued. My workers' compensation insurance calrier and policy numtrer are: <br />grr1"r. S a.,Jv.-\-}\ ,'+tar\P.\ <br />Sq^J< tZ\ Eg \t <br />['ixpires:e/,r I ro <br />Policy Nutnber:_ <br />-l <br />certify that in the perforrnance of the work for which this permit is issue<I. I shall not employ any person in any manner :so as lo become subject to the workers' compensation laws of California. and agree that if I should become subject to the <br />workers' colnpensation provisions of Section 3700 of the Labor Code. I shall. forthrvith comply with those provisions. <br />WARNING: Failure to serure workers' cornpensation coverage is unlarvfrrl. and shall subject an onployer to crirninal pcnalties qnd <br />civil l-rnes up to one hundred lhousand dollars ($100.000). in addition to the cost of compcnsation. damages as provided forlhe <br />Section -1076 of the l-ahrr Code. interest and attorney's <br />\()t J L\b tr^e\^\\qtu,, <br />I hereby alTinn under pcnalty of perjury that I am licensed under 9 (comrnercing w'ith Section 7000) of Division 3 <br />of the Business and Professions Code. and rny license is in full ftrrce and effc'c't. <br />to(3-7e3License Class: C <br />uate: tt/ zr lq h.trro* S utr \sot\<ttoa' <br />CONSTRUC'TION LENDING AGENCY <br />I hwby allirm under Jxnalty of pcrjury that thqe is a construction lending agcncy for the pqfomance of the work for which this pmit is <br />issued (Sec. -j097. Civ. C.). <br />Lender's Narne: <br />- <br />Lender's Address: <br />- <br />APPLICANT DECLARATION <br />I lEdry alfm unda pcnahy ofpcrjury onc ofthc following delarations: <br />Dsnolition Pmtrits-Asbstos Notification Fcdqal Regulatiors (Titlc 40, Part6) <br />_Rcquircd t ats of Notificrtion <br />hhcdiry rhd thc fcdoal rcgulatiore rcguding cbetos rmoval rc not spPlicablc to this prcjcct. <br />_l cdiry that I havc red this applicatioo and statc that thc above infomation is corcct, I agrE to omply with all City ud Counly <br />ordimnc6 ed Ststc Law rclatitu to building construcrion and h@by authorizc rcprMtdiv6 of thb City ed Comty to 6ta upon thc <br />above rnentioned property for <br />Applicnnt or Agent <br />Pernritee nilnre (print):Lg T**.\\c, <br />Ir Lt <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bfloor/VenUl n su lation <br />Roof Sheathing <br />Shear Wall <br />Framing <br />lnsulation/Enerqy <br />Drlnvall <br />Ext./lnt. Lath <br />Brown Coat <br />I\/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />I I <br />FINAL t tula)D kf/)r'-*yq <br />Certificate of <br />Note Re Etc. <br />0 b <br />t <br />I Jt <br />Arrolicant: <br />t <br />\ <br />I (o- <br />t!