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BU!LDING. INSPECTOR RECORD SITE-WORK DATE ID/SIG.COMMENTS OWNER BUII,DER DEI.CARATION I hererr;L aflirm undq pflalty of pqjury that I an cxcmpt from lhc Coittraclon' Liccmc law for thc following reen (Ss.7031.5 Businss and Profession Code): Any City or County which rcquir6 a p6mit to construct. altq. improve. donolish or rcpair my struclure. pdor to ils issuace. also requirG the applicut for such pemit to lile a signed statmmt that hc or shc b licmsd puEuill to lhe trovisioB of thc ('ontractor's Licenscd l-aw (Chapto 9. Commencing rvith Sstion 7000 of Division 3 of thc Busincrs an'd I'rcfe$ions Code) or that he or shc is cxempt theefrom md thc bsis for thc alleged exmption. Any violation of Sation 7031.5 by any applicantforapemitsubjetsthe applicanttoacivilpenaltyofnotmorethilfivehundrcddollm($500). -1. as owner of the property. or nly employees with rvages as their sole conrpensation. rvilldo the rvork and the structure is not intended or offered for sale (Sec.7044. Business and hofessions Code: The Contractor's License Larv does not apply to an orvner of the prcperly who builds or improves theron. and rvho does such w'ork hirnself or herself or through his or her own etnployees. provided that such inrprovonenls are not intended or offerd for sale. I[, hos'eter. the building or improvemeflt is sold within one ]â‚¬ar of completion. the Olvner Builder will have the burden of proving tha he or she did not build or improve thc propo'ty for the ptrposc of sale). I -1. as owner of the propei'ty. am exclusively contracting rvith licensed conlractors to construct the project (Sec. 7044. Btsiness and ProfEssion Code: f'he Contractor's License Law does not apply to an otvner of property who builds or improves thereon. and rvho contracts for such projc.cts rvith a Contracto(s) licensed pursuant to the Contractor's License Larv). -IarnexemptunderSection-.B.&P.C.forthisreason. 1)ate:On ner: \!'O RK l.l lts' ('()1\t PITNSn'l'1() N DTi('I,ARAI'ION I hereby alfirm under penalty of perjury one of the following declarations: -l have and will maintain a Certificate of Consent to Self-lnsure for workers' compensation. as provided for by Section -j700 of the Labor Code. for the performance of the work for rvhich the pennit is issued. -l have and will maintain workers' compensation insurance. as required by Section -1700 of the Labor Code. for the performance of the rvork for which this pennit is issued. My rvorkers' compensation insurance carrier and policy numbcr are: tIcu,in, lbelr, uoA4t-< \ CaS, ,^l 4 / / Policy Numaer: Actt â‚¬-1r2r-; t L{ 7 Expires: -l certi& that in the performance of the work for which this perrnit is issued. I shall not anploy any person in any manner so as to become subject to the rvorkers' compensation laws of California. and agree that if I should become subject to the . workers' compcnsation provisions of Section 3700 of the l-abor Code. I shall. forrhwith comply rvith thosc provisions. WARNING: Failure to secure workers' compensation coverage is unlawful. and shall subject an onployer to criminal penalties and civil fines up to one hundred thousand dollars ($100.000). in addition to the of dzunages as provided for the Section 3076 Labor Code. interest and attorney's fees. // I lrerchy alfirrrr under penalty of perjury that I iun licensed provision of ('hapter 9 (comrrrencing rvith Section 7000) of Division 3 of the Business and Professions Code. and nry license is in fult force and effect. iq0License ct^rr, (' '-J ? Date:_ l,icense Nurnbcr:{3 Contractor:_ -I hereby affrrm under pcnalty of perjury that there is a issued (Sec. -j097. Civ. C.). Lender's Narne: lending agency for the performancc of the rvork flor rvhich this p,ermit is l-ender's Acldress: APPLICANT DECLARA'TTON I heretry aflinn under penalty of pe{ury one of the follorving declarations: Demolition Perrnits-Asbestos Notification Federal Regulations (T'itle 40. Par16) _Required Letter of Notification -l cgtify that rhe fedcral regulatioN rcgdding Gb6tos rcmovalile not applicable to this prcj61. -l cdify that I havc Md this application and statc that thc above infomaion is corct. I agreto omdy with all City and Couty ordinancB ild Statc taw rchting to building consrucrion. ed brrty authorirc rcprGfitalivc of this City md County to 6tq upon the above mcntioncd prcpcaty for impetion purposy' ,y'' " / AppricsnrorAgmrsieo.rrn K4rt''t -l'- n","/a // q Pmirenlme(prinq, / {F4t,y' (lrArt" Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloor/Ve nUI ns u lation ,, Roof Sheathing r'Z /t 2,1 7 f4,?r c{ Shear Wall Framing lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Flnal Report Flood Zone Certif t/t -\F!NAL //E/zo ,lz!-Lffit //t7 7 VVCertificate of Occu pancy n / I v I