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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hqeby allirm unda pemlty of perjury that I an cxempt from lhc Contrilton' Licw Lars for thc following rcmn (Ss.703i.5 Buinss md Profesion Code): Any City or County which rcquira a pmit to coEtruct, altq. imprcve, dcmolish or repair my structue prior to its isuancc. also rcquirc thc applicant for such JEmit to file a signed statmqt that hc or shc b licosâ‚¬d pmumt to the provisiore of the Contractor's Licord Law (Chapt6 9. Commcncing with S*tion 7000 of Divbion 3 ofthe Busins md Prefe$ions Code) or that hc or shc is cxmpt thscfrom and lhc basis for the allcged crmpion. Aoy violation of Scc{ion 7031.5 by atiy applic-ant for a pqrnit subjsts thc spplicml to a civil pcmltyof not morcthu live hundrcd dollas ($500). ftlr* owno ofthc prcpeny. or my cmployo with waga r their rcle compruation. uill do rhe lvork atrd ttt gnrtuc b rct intoded oroflH for elc (Se.7044. Busin6s ild Prcf6ioN Codq Thc Conlractor's Licme law doe not apply to M own6 of thc popcrty uho builds or imptovs th6@n. md sho d6 such *ork himsclf or hmclf or thrcugh his or ha own cmphyc. provided Ihat such imprcvflflts m mt intoded or ofli:ql for sle. lf, howryq. the building or imprcvcrcnt is sld within one )w ofcompleion. thc Orvnc Builds rill have the burd6 ofprcving Ihd he or dE did not boild or iqrovc thc tropqty for tlE purposof sle). - l. as owner of the property. iun exclusively contracting rvith licensed contraclors to conslruct the proiect (Sec. 7044. Business and Profission Code: The Contractor's License Las' does not apply to an o$'ner of propâ‚¬rty who builds or improves thereon. and who contracts for such projects with a Contractor(s) licensed pursuant to the (-ontractor's License [,arv). _l arn B.&Ibr tlris I)ll[:Or"na.\\(), DECLARATION I hereby affinn under penalty of perjury one of the follorving declarations: -l have and rvill maintain a Ccrrificatc of Consent to Self-lnsure for workers' compcnsation. as provided for by Section -3700 of the Labor Code. for the performance of the work for which the pennit is issued. -l have and will rnaintain workers' compensation insurance. as required by Section 3700 of the Labor Code, for the perfonnance of the rvork fcrr rvhich this pcrrnit is issue<t. My workers' compensation insurance carrier and policy numk are: Carrier:- Policy Number:_ -Expires: - &{f cenify ttat in thc perfomance of the work for which this permit is issued. I shall not qnploy any pmn in any mune s 6 to bccomc subj$t to the workffi' compmsation laws of Califomia. and ag@ that if I should beome subjet to the rvo*m' compwttrn prcvisions of Scaion -1700 of lhc Labor Code. I shall. forthrvilh comply s ith tho$ previsions. WARNING: Failure to sure workm' compensation covmge is unlarvful. ud shall subjet an mploye to qiminal penaltis and civil finc up lo o0a hrndrd lhoMd dollffi ($100,000). in sddition lo the cosl of compensation. dmag* o providcd for thc , Section .1076 Labor Code. intercst and attorney's fees. I hereby affirm under penalty of the l]usincss arrd Professions Code. and rny license is in [ull force and eflect. License Nurnber: ('onlractor: CONSTRUCTION LENDINC AGENCY I hmby affm undo penalty of pedury lhd th@ is a congruction lcnding agocy for the pcrfomce of the work for shich this pqmit b issued (Ss. 3097. Civ. C.). Lendd's Namc: Lender's Address: APPLICANT DECLARATION I herebry aflinn under penalty of perjury one of the follorving declarat ions: Dernolition Perrnits-Asbestos Notification Federal Regulations (I'itle 40. Par16) _ Required Letter of Notification - lcotirythatthefedoalregulationsregrdingasbestosretrnvaltrenotapplicabletothisprcjst. LLt cqtify rtar I have read this application ild statc that the above infomation is coust. I agrre to comply wilh all ('ityand County arrdinancs and State la$s rclating to building connrudion. ild hqeby authorize reprGotatils of this City ud County to 6tq upon the above mentioned property for inspection purposes. Appticnnr or Asenr sisnrrrr"'-\Q6( ._\L)Q!\ -Dg [ -AY2 pernriree nnme trrin,l, JOS- -r-@ 3b- - -oate: f f tslu- Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground \ SLAB Floor Su bfloor/VenUI nsu lation Roof Sheathins lLf lul 4 tr L(n )r \U Shear Wall t I Framing Insulation/Energy Dryruall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif t^ FINAL //?c/ /zD n Certificate of Occu Notes, Remarks, Etc. License Class:_ Drte:_