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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG COMMENTS OWNER BUILDER DELCARATTON I hcrchy afftrm undcr Fnalty of Frjury that I m cxcmpt thrm thc ConlractoN' Liccnrc hw for thc li)ltrwin8 rca$n (Scc.70.l1.5 Busincss anl Protbssion Code): Atry City or County which rcquircs a lrcrmit k) qrnstruct. altcr. improvc, dcmolish or rcpat any struclurc, prior to ils issuancc, also rcquircs thc applicant li)r such lEmit lo l'ilc a siSncd stalcmcnt that hc or she is lienscd pusuant to thc [n visions of tlE Contractor's Liccnscd ltw (Chaltcr 9, Commcncing with Scction 7fi)0 of Division 3 of thc Busincss ud PrulbssionsCodc)orthathcorshciiexcmptthcrcfromatulthchasisforthcalleScdcrcmption. AnyviolalionofSetionTOJl.5byany applicant for a trcrmil suhjsls the applicant b a civil pcnally ()f n(il m)rc lhm tivc hundrcd doll&s (Ssfi)). /l-4$" ,r*n .rf thc prclrny, or my empl)yes wilh wagcs as thcir solc com[Ensation, will rlo thc wtrk axl thc strctm is nol intcnlql or otcrcd tbr slc (Se.7O44, Busincss and PR fcssi(rns c(i.lc: Thc Contrrckrr's Liccnsc kw docs not apply to u owncr of thcpnlJE.ty whohuildsorimFovcslhcG)n,anlwhod(rcssuchurrkhimsclforhcrrclforthftrughhisorhcrowncmployecs, prcvidcd that such impnrrcmnts m mt intcndcd orollbql tir slc. Ii horcvcr, thc huilding or improvcmnt is srll withitr onc ycu of comphtiln, thc Owrcr Buil,ler will hare thc huniur of prcving that hc or she dil nil hui&l or in{row the Imfdy for thc turlns of sb). _1, as owner ot'the pn)Frty. am exclusively contracting with liccnscd contractors lo constluct thc pnljcct (Sec. 7044, Busincss an.J [tutbssionCrxlc: I'hcContractor'sl-iccnscLawdocsnotapplyloanownerofprolrcrtywhohuildsorimprovesthcrcon, and who conlracts firr such projects with a Conlractor(s) liccnscd pursuant to thc Conlractor's Liccnsc Law). _l am exempt undcr B. & P.C. tirr this rcason. a 4 I hcrcby alfirrn undcr lL-nalty ol'Frjury onc ol thc lilllowing _l have and will mainlain a Certilicatc of Conscnt to Self-lnsurc ti)r workcrs' comlrcnsation, as providcd tbr by Scction 37fi) of the Labor Cule, lbr the grcrlbrmance of thc work tirr which the grcrnrit Ls issucd. _l have and will maintain workers' comJrcnsation insurance. as rcquired by Scction 37fi) of thc Labor CrxJe, tirr the ;rrftrrmance of thc work tbr which this Jrcrmit is issued. My workcrs' comlrcnsation insurancc c.urier an-l Sxllicy number are: Carricr: Policy Number: Expircs: .A l/..f.Lnif y,m, in thc lrcrlirrmrec ()f thc work tir whi.h this fErmit is issucd. I shall nol cmploy any lrcson in any Mncr ' so as k, beom subFct t, thc wod(crs' con[rns.tion laws of Calitirmia, and agrce thal if I slxruld tsorc suhjcu b lhc workcrs' @mlEnsati(rn pruvisions of Selion 37m of lhc tlhor Gxlc. I shall. forthwith comply with tlf,rs provisions. WARNING: Failurc l(, surc workcrs'q)mlEnsation covcragc is unlawful, and shall suhjcrt m cmplrrycr to sininal ltmltics ild civil lincs up lo orc hundrcd thousand dollus ($100,0m). in additkrn lo lhc cost of compcnsation, damges as providcd for thc Scction .1076 of thc Latxrr Cdc, intcrcst and allomy's fecs. ta I hcrchy allrm undcr penalty of pcrjury l ol' thc Busincss and Prol'cssions Codc, iud nry liccnse is irr lirll lirrcc- iutd ctfbct. l,iccnsc Class: Liccnsc Nuntbcr: Il.. a n.f r^al ra^rnr. W I hcrchy aflirm undcr trcnalty of pcrjury that thcrc is a onslruclk)n bnling agcncy lirr thc lErlol:lrwce of thc wor* for which this lmit is issucd (S@. 1097. Civ. C.). k'ndcr's Name: krrdc-r's Addrcss: APPLICANT DECLARATION I lrcr.-hy attirm undcr Fnalty of perjury onc ol'thc lbllowing dcclarations: f)cmolit iorr Permit s-Asbcslos Notificat ion Fcdcral Rcgulat krns ('l-it lc 40, Part6) _Rcquircd l*ttcr of Notifrcalion -l certily that the lcdcral rcSulations rcgruding asbcsk)s rcmlvol rrc no( applicahlc lo this pmjcct. Ll.cttify that I havc rcad lhis application anl state that the atnvc infomlion is corcct. I a!re to @mply with all City and Counly oRlinanccs ed Stalc llws rclating to buikling conslruction, aril hcrcby authorirc rcfcscntalivcs oflhis Cily ed County to cntcr uF)n tlE atxrvc mntiorcd p$[rc]ty lbr inspeclion puFrss. AppricsnrorAsenrsrrn rrnYrrl d I t .r r(4, ); ^ ", **, - O l' 7' 2- O Permiteename(orint):K -.14 O{'r A .tt4 {- 11 ira C Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenUl nsu Iation Roof Sheathinq Shear Wall Framing Insulation/Energy Drywall Ext./!nt. Lath Brown Coat JVlasonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif t//A FINAL alaflo TU6, nh) Certificate of Occupancv t I Notes, Remarks, Etc. + b