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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE !D/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hocb affirm und6 pcnalty of perjury lhal I m exmpt frcm the Conlracto6' LiccN taw for thc following r@n (Sft.7031.5 <br />Busins ad Prof6sion Codc): Any City or County rvhich rcquire a pornil to construct. alt6. improvq donolish or repair uy <br />structuc. prior to its isuacc. also rcquirc thc applicilt for such permit to filc a signcd statmot that hc or shc ir licos€d pmuot <br />to thc prcvisioN of the Contractor's Licemed Law (Chapt6 9, Commencing with Setion 7000 of Division 3 of thc Businss md <br />PrcfessionsCodc)orthatheorshciscremptthqefromildthcbsisfortheallegedermption. AnyviolationofS€1ion70-1l.5byany <br />applicantforapennitsubjetsthc applicilttoacivilpcnaltyofnotmor€thmfivehundrcddollds($500). <br />I L-L * omo of the propcny. or my employc wilh wag6 6 thcir sle compeBtion. s,illdo thc wort ad thc structre b nol <br />''iil-qded oroffrcdforslc(Se.7044.B6iosildhofeiomCodqThcContraclor'sLicorc[awdo6notEplytoilomsof <br />lhc prcpsry rvho tuilds or imlrcvc th@n. od who do6 such uort himself or hmlf or thrcugh his or ha orn mploye. <br />provided that such improvomts rc not inqdcd or oflqcd for slc. If. ho*ao. the buiHing or improvmot is rcH within one )s <br />ofcompktiou the O*ns Builds will have thc hrdm ofproving that hc or she did mt build or improvc thc popoty for tlE purpos of <br />slc). <br />-1. <br />as owner of the plopetly. am exclusively contracting with licensed contractos to construct the project (Sec. 7044, Business <br />and ttofession Code: 'I'he Contractor's License Larv does not apply to an orvner of property who builds or improvcs thereon. <br />and who contracts fior such projects with a Contractor(s) licensed pursuant to the Contraclor's License Larv). <br />_l am exempt und€r Section_.for this reason. <br />,^,",_.,, /-2, /, q 0wner:}{- <br />I hercby affirm under pcnalty of pojury one of the follos,ing cleclarations: <br />----l haveandwill maintainaCerlilicateofConsenttoSelf-lnsureforworkers'conrpcnsation.as providedforbySec'tion3700ofthe <br />Labor Code. for the perfonnance of the u,ork for rvhich the perrnit is issued. <br />- -l have and u'ill maintain rvorkers' cotnpensalion insurance. as required by Section -3700 of the Labor Code. for the perfonnance of <br />the u'ork for u'hich this p,ermit is issued. My rvorkers' compcnsation insurance carrier and plicy number are: <br />Policy Number:--[ixpires: <br />lb ,rtity tt xin the psfomancc of the work for which rhis pqmit is issucd, I shall not mploy any penon in any mmno <br />$ c to trccome subjet to lhc work6' compqslion laws of Califomia. and 89rc that if I should baomc subjet to thc <br />so*ffi' compeffition prcvisioro of Seoion 3700 of thc l:bor Code I sfull. fo(hrvith comply with tho* prcvisiom. <br />WARNTNG: Failure to surc uorkm' compf,etion covoagc is unlasful. md shall subjst o mploF to qiminal pcnahis ud <br />cilil fine up lo onc hun&ed thoMd dollm ($100.000). in addition to lhe cosl of compwtion. dmag6 I proiidcd for thc <br />Section -1076 of the Labor Code. interest and attorney's fees. <br />. tl <br />l)1,,('1,,\RA'l'loN { <br />I hereby affinn under penalty of pcrjury that I arn licenserJ under provision of Chapter 9 (commencing rvith Section 7000) of Division -i <br />of the Business and Professions Code. and my license is in full force and eflect. <br />License Class:_License Number: <br />Date:---_('onlrnctor: <br />CONSTRUCI'ION LENDING AGI]NCY <br />I hereby affmn unde pcnahy of psjury that th6€ is a constructkrn lmding agency for thc pafomace of the $ork f<rr rvhich this pemrit is <br />issued (Sec. 3097. Civ. C.). <br />Lender's Name: <br />Lendcr's Address: <br />APPLICANT DECLARATION <br />I hetfoalfm unde poalty of pcrjury onc of thc following dclrations: <br />Demolition Pqmits-Asb6tos Notification Fcdqal Rcgulations (Titlc 40. Put6) <br />-Rcquired <br />trtte of Notificalion <br />-l <br />cqri& thst the lidqal rcgulatioru r€Bilding abctos rmoval ue not spplicable to this prcjet. <br />4lf"otity Ita I havc r@d this application md slatethat lhe above infomalion is corcct. I agrc to comply rvith all City and County <br />ordinatrc6 ad Stale taws rclaing to building conslruclion. ed hscby authorizc reprMtative of this City md Counly to mtq upon thc <br />I'enrriree nnnre (prinr): t Ail U fO lcl <br />r)nrc: D tr ffi / ,q <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />LJFER Ground /r' <br />SLAB Floor 1 <br />S u bfloor/VenUl n s u Iatio n <br />Roof Sheathing <br />Shear Wall <br />Framing <br />!nsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report /l , <br />Flood Zone Certif r*., <br />FINAL lza e -t?O6tt{lat <br />Certifi cate of Occqpg rlrcy <br />Notes, Remarks, Etc. <br />-