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BUILDING- INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcrcby affirm undo pmalty of pcrjury that I m qmpt from thc ConlractoE' Licmrc lanv for thc following rcmn (54.70315 Busincs md Profcssion Codc): Any City or County which requirs a pcrnit to construct. altq, improvq dmolish or rc1}ai... uy structue Fior to its ismce. also rcquirG the applicet for such pcmit to filc a si8ncd statmot thst hc or shc irmscd pEuut to thc provisions of thc Contractor's Licmsed taw (Chapts 9, Commcncing with Sction ?000 of Divisiotr 3 oi the Busins md Prefc$ions Code) or that hâ‚¬ or she is qmpt lhgcfrom md thc basis for thc allegql cxorption. Any violalion of Sslion 7031.5 by anv applicantforapcnnitsubjctsthc applicmttoacivilpenaltyofnotmorcthmfivehundreddollus($500). l. u ouno ofthc popcrty. or my employm *ith $ ag6 6 thcir ele compcnsstion. sill do thc sork md thc stnriw is not intmdqt or offcrcd fq slc (Sc.7044. Busine ild ProfessioB Codc: Thc Contraclor's l.icN Larv do6 nol 4ply to m oma of rhc prepsty rvho tuilds or improvq tha@[ ad who do6 $ch m* himself or hcNlf or lhrcu8h his or hc own cmployco. providcd that such itnprcvmts rc rct intadcd or offdEd for sle. lf. howM. thc buiHing or impo'mt is $H lvithin one )@ Lfcompteion. the Owne B{ikkr will harc ttE htrdo of prcving thd hc or shc did not buiu or impo\c thc Propqry for thc purpoEof sle). _1, 6 ownq of the prop6ty. m cxclusively contracting with liccnscd contractoE to construct thc prcjcct (Sc. 7044. Buine md Profesion Code: Thâ‚¬ Contractor's Liccns Law do6 not apply to il ownq ofpropcrty who builds or imprcv6 ths@n. and who ontncls for such prcjets with a Contmcto(s) licosd PuEWt to thc Conlractor's Licqre [rw). -l m cxcmpt undq Setion---. B. & P.C. for this trcNn. l)ale: I hcrcby O*nu.t DECLARA'I'ION alfirrn under penalty of pojury one of the follorving declarations: _l have and rvill ,naintain a Certificate of Consent to Self-lnsure for workers' compensation. as provided for by Section 3700 of the Labor Code. for the performance of thc work for which the pennit is issued. _l have and will maintain workers' compensation insurance. as required by Section 3700 of the l-abor Code. for the performance of thc rvork for which this permit is issued. My workers' compensation insurance carrier and policy numLrer are: Carrier:- ; Policy Nurnber:-Expires:,r/2 -Z cqiify thot in thc psfomancc of thc work for which this pqmit is issued, I shall not mploy any pGon in any mmnc- e s to beomc aubjat ro thc sortm' compqution las of Califomia. ud agrc Ihd if I should bccomc aubjet to the so*G' cotnpcgtion prcvisioro of Sation 3?00 of thc Labor Codc. I slull. forthwith comply with thor provisions. WARNING: Failure to suc wrk6'compensation covragc is unlawful. and shall subjct m mploys to simiml penaltics md civil fine up to one hundrcd thousd dollm ($100.000). in addilion lo the cost of compenetion. damge r providcd for the Section -1076 of the Labor and attorney's fees. (,I I hereby affirm under penalty of perjury of the Business and Professions Code. and rny license is in full force and effbcl. (,..n.. class:- C {,*", I // -, n +aLicense Numbcr: Contractor, ?-KtLK ME ,n erronnance ,*n":,:("#-YA-I hereby afTirm under penalty of periury that issued (Sec. 3097. Civ. C.). Lender's Name: Lender's Address: APPLICANT DECLARA'TION I hoEty aflirm under penalty of perjury one of the follou'ing declarations: Dernolition Permits-Asbestos Notification Federal Regulations ('title 40. Pafl6) . -- Required l.etterof Notification __l certify that the federalregulations regarding asbestos removalare not applicablc to this projecl. Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/Ve nUl n su latio n Roof Sheathinq Shear Wall I \,av^a Framanq --ll 2G n DA,wa rgv lnsulation/Enerqy Drwvall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report \ Flood Zone Certrf .aa I \3, FINAL lr 'll/F {arwnal , s.d Certificate of Occupancy I I Notes, Remarks, Etc. \ \ Z ft havc reacl this application and state that the abol'e inlorrnation is correcl.agree to conrply u'ith all City and County ordinances artcl Statc Larvs relating building construction.hereby aut horize reprcsentat ives o f this City and County to cnlef ugrcn the above rnentioned properly for insperction purposes. or Agcrtt Sigrtaltrre: l'ernrilee nIrno (prirrt): zutd L ,-a-t" ,*", lM