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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARA'I'ION <br />I hoeby aflim unda pcnahy of perjury thd I m cxcmpt ftom thc Contractoc' Licffs Law for thc following r@n (Ss.7031.5 <br />Bcin6s and hofruion Code): Any City or County u'hich rcquirc a pamit lo construct. ahc. improvc. dstrolish or rc?air ily <br />structura prior to its issuilcc. also rcquic the applicant for such pcnnit to file a signcd stdmmt that hc or she is licosed Pmuot <br />to thc previsions of the Contractor's Licenscd law (Chaptr 9. Commencing wfuh Strtion 7000 of Division 3 of thc Busins and <br />PrcfcsionsCode)orthatheorshciscxcmptthqefromandtheb6isfortheallegcdermption. AnyviolationofSetionT03l.5byany <br />applicant for a pmnit subj(ts lhc applicant to a civil penalty of not more thil livc hundred dollqs ($500). <br />__1. m ownq of thc property, or my mployc with wag6 6 thcir sle compensation, will do the work md the stnEtw is not <br />into<lql or oflscd for sale (Se.7M4. Busin6s sd Pref6sioc Code: 'Ihe Contraclor's Licms Law do€ not apply to il orwq of <br />thc prefEty rvho boilds or irnprcve thmn. md s,ho do6 such uork himself or hffilf or thtough his or hr orn onployec. <br />provided that such imprownts e not inlodcd oroffqed for sh. lf. horvq'q. the building or hnproEmt is rcH wilhin one )a <br />;fcomplction, thc ownq Builds will have thc btudcn ofproving that hc or shc did not build or improw the prcpoty for the pupo$ of <br />sle). <br />_1. s oM6 of thc propqty. m exclusivcly contractitrg with licsd contraclosto coNtruct lhe proj(t (Se. 7044. B6in6 <br />and Profxsbn Code: Thc Contrrctor's Liccnsc Law do6 not apply to m ownq ofprop€rty who builds or improves thq@n, <br />ud who contmcts for such projects with a Contracto(s) licqsed pursuilt to thc Contractor's Lic6c kw). <br />-l <br />zun exernpt under Section B. & P.C. for this reason. <br />Date:_Owner:_ <br />WORKERS' COIlTPENSATION <br />DEC!.A8AIIO! <br />I hocby allim undo pcnahyofpcjury of,e ofthe following dcluatiom: <br />_l havc and will maintair a Ccrtificate of ClMt to SGlfJNure for rvorko' compwtion, c providcd for by Setion 3700 of the <br />Labor Code for thc pafomcc of the work for which thc pcmil b isued. <br />V(ile and will maintain workm' compesation insurance. I rcquircd by Setion 37OO of lhe tabor Codc. for thc pafomocc of <br />/ihE/rvork fior which this pcrmit is issucd. My work6' compwtion iruurece cuiq md policy numbo uc: <br />C-s. <br />Policy Vtr Expires: ? /r /s q) <br />t <br />_l cerrify that in the perforrnance of the work for u'hich this perrnit 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 become subject to the <br />workers' compensation provisions of Section 3700 of the Labor Codc. I shall. forrhwith cotnply with those provisions. <br />WARNING: Failure to secure workers' compensation coverag,e is unlau'ful. and shall subject an onployer to criminal penalties and <br />civil fines up t9 one hundred thousand dollars ($100.000). in addition to the cost of compensation. datnages as provided for the <br />Section 3076 the l-abor Code. interest and attorney's fees. <br />S- q., <br />DECLARATTON <br />I hereby alfirm under penalty of perjury that I arn licensed under provision of Chapter 9 (comrnencing rvith Section 7000) of Division 3 <br />of the Business and Professions Code. and rny license is in full force and effect. <br />8qx&eLicense ctass C. I a) <br />,.* <br />l.icerrse <br />I <br />CONSTRUCTION LENDING AGENCY <br />I hrcby affrm unda pcnalty of psjury that thoe is a construc{ion hnding agmcy for the pqfollmce of thc work for which this p<tnit is <br />issucd (Sc. 3097. Civ. C.). <br />Lender's Name: <br />Lender's Ad&ess: <br />APPLICANT DECLARA'TION <br />I hac{ry affrnn under penalty of perjury one of the following declarations: <br />Demolition Pernrits-Asbestos Notification l;ederal Regulations (l'itle 40. Pat16) <br />-Rcquircd <br />lrttq of Nolification <br />-l <br />cgriry that thc fcdral rcgulatioro rcgrding sb6tos rmoval uc not applicable to this prcjerc,t. <br />_l cdify that I hsvc r€d thb application ild statc that thc abovc infomation is corcct. I agr€to comply with all City and County <br />ordinancB od State Laws relaing io building coNtruction, ard h€rcby authorizc rcplffitdivB of this City ed County to 6tq upon thc <br />above rnentioned property for <br />,,,., lt luoJtlApplicnnt or Agent <br />Pernritcc rrAnle <br />Set Backs <br />Forms/Stee!/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bfloor/Ve nUl nsu latio n <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />[/asonrv <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />// <br />FINAL // (/hto f LJ et0O <br />Certificat6 of 'Occu pancy <br />Notes <br />-U l,J </ <br />('ontraclrlr <br />- <br />1-lr"^f