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BUILDING. INSPECTOR RECORD <br />S!TE.WORK DATE ID/SIG COMMENTS ()wN t,lR llt, I l,l)llll I)lit,('A ll^'l'loN <br />I hcreby afiirm unde pculty of perjury that I m cxempt ftom thc Conlractos' Licnrc taw for the following @{,n (56.7011 5 <br />Bsin6s md profsion Code): Any City or County which rcquire a pemh to onsirucl. altq, imprcvq dcmolish or repair my <br />structurc, prior to its issusce. also rcquirB thc applicant for such pcmit to filc a signcd statmmt thst hc or shc is licmscd pmust <br />to the prcv6io6 of thc Cootractor's Licenscd trw (Chaptq 9. Commcncing rvith Sction 7000 of Division 3 of thc Busine md <br />prcfesionsCodc)orthathcorsheisexemptthgeFomildthebasisforthcallcgcdcrmplion. AnyviotationofSethnT0-ll.5byany <br />applicant for a pmit subj(ts the applicant lo 8 civil pcnallyof not morcthm livc hundrcd dollrs ($500). . <br />_1. c owncr of lhe Fopcfly. or my cmplo,6 with sag6 s their sle compcnsalion. *ill do thc work ard thc stnrlw is not <br />intqrdcd or offqed foi rlc 1sc.7fin. nwins md Prcfoiom Codc: The Contraclor's Licffi law doc not qply to il omo of <br />thc propqiy who buil& or improvc thron, and who doa such mrk himclf or hmlf or thrcugh his or ha om mploycc. <br />prorided rhat such imprcmB e rct irtodcd or offsql for elc. lf, howd6. the building or improml is mld within one yw - <br />of corrplaion thc Orna Builds will have thc h[den of proving thli h€ or shc did rct build or improvc thc popary for thc prposof <br />ulc). <br />l. sowns of the pfopqty. m cxclsively cortracting with licosed contractoE to construct th€ projcd (Sd. 7M4. B6ins <br />ad profusbn Code: Thc Conrractor's Licensc Law do6 not apply to m orvno ofpropoty rvho builds or imprcv6 thfr@n' <br />and who contmcts for such plojets with a CootEclo(s) licmcd puEmt to lhc Contractor's Licre taw). <br />-l <br />m cxempt undq Sation---. B. & P.C. for this r@n. <br />l):rlc: ()rvlttr: <br />WORKEIIS' COMPENSATION <br />DECLARATION <br />I hereby affirm under penalty of perjury one of the follorving declarations: <br />_l haye an{ will maintain a Certifrcate of Consent to Self-lnsure for workers' compensation. as providd for by Section -3700 of the <br />Labor Code. for the performance of the work for which the pennit is issued. <br />_l have and will rnaintain workers' compensation insurance. as required by Section 3700 of the Labor Code. for the perfonnance of <br />the u.ork for which this permit is issued. My workers' compensation insurance carief, and policy numhr are: <br />canier: P A ltne YiCa Yn lru n G, <br />PolicyNr-b-,' \y' C tt ZS (1, 3 L <br />-Expires: <br />t n/'1? <br />_l certi& rhat in the performance of the rvork ftrr rvhich this pernrit is issued. I shall not etnploy any person in any tnanner <br />so ils lo become subject to the work€rs' compensation laws of Califcrrrria. and agree that if I should become subjc'ct to the <br />g,orkers' compensation provisions of Section -3700 of the Labor Code. I shall. forrhrvith comply rvith those provisions. <br />WARNINC: Failure to secure workers' compensation coverage is unlarvful. and shall subject an anployer to crirninal pcnalties and <br />civil fines up to one hundred thousand dollars ($100.000). in <br />Section 3076 of the tabor Code. interest and attorney's fees. <br />cost of compensation. damages as provided for the <br />D t\LI (D( <br />l.r(' rrN s Ep ('oN'I'RA( "1'()R <br />l)11('1,,\R,\'l'l0N <br />I hereby affirm under penalty of perjury that I arn licensed under provision of Chapter 9 (cornmencing with Section 7000) of Division -l <br />of the Business and Professions Code. and my license is in full force and effect. <br />? <br />e <br />License rr^"t. cl,.O I c-Yb <br />,,,", e l({V{ <br />f Ullrontrac,or: <br />Licensc <br />ol 6,1.? ) bb <br />I <br />CONS'IRUCTION LENDING AGENCY <br />I hcrcby a{Iirm unda penslty of pcrjury thd th6c is a congruc{ion lading ag6cy for the pcrfomocc of thc work for which this pcnnh b <br />issued (Se. -1097. Civ. C.). <br />Lender's Name: <br />- <br />Lender's Address: <br />APPLICANT DECLARA'I'ION <br />I luelry affrrn under penalty of perjury one of the follos'ing declarations: <br />Pernrits-Asbestos Notification Federal Regulations (f itle 40. Pan6) <br />[.etter of Notification <br />€_l certify that the federal regulations regarding asbestos removal are not applicable to this project. <br />certify that I har,e read this application and slate rvith all City and County <br />and County to enter upon theand State Laws relating to <br />atxrve rnentioned properly for inspectitln <br />Applicant or Agent Signalure:-f <br />- <br />l'ernrilee nfl nre (print):)(-v44l_ <br />,,r",'l({UlUfi <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bfloor/VenUl ns u lation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonrv <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flpod lqle Qertif. IS)lavr\ffir *nfu <br />l \r ,A <br />FINAL I lIOo (uu$&i(ft/ <br />I YCertificate of Occupancy <br />Notes, Remarks, Etc. <br />-) <br />Alz.aa <br />Ir a <br />l 70zo N