101106973 - Permit - Laserfiche WebLink

Home Browse Search

BUILDING. INSPECTOR HECORD SITE-WORK DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION I hcrcby affirm undcr Jrcnalty of pcrjury that I am exempt from thc Contractors' License [:w for thc following reason (Scc.7031.5 Business aml Profcssion Code): Any City or County which rcquires a pcnnit lo conslruct. altcr, improve, dcmolish or rcpair any structurc. prior to its issuancc. also requires thc applicant for such pcrmit to file a signcd statement lhat hc or shc is licenscd pursuant to thc gnovisions of thc Contractor's Licensed Law (Chaptcr 9. Commcncing with Scrction 7000 of Division 3 of the Business and Professions Codc) or that hc or shc is cxenqrt thcrcfrom und thc basis for thc allcged exemption. Any violation of Scction 7031 .5 by any applicant for a permit subjects thc applicant to a civil penalty of not morc than fivc hundrcd dollars ($500). -1. as owrrcr ol'thc prof,eny. or my cmployees with wagcs as their sole compcnsation. willdo the work and thc stnrcture is nol intcnded or ofl'crcd lbr salc (Scrc.7U14. Busincss and hofcssions Code: The Contractor's Liccnsc law does not apply to an owncr of thc prcpcrty who builds or improves tlrcrcon and who does such work hirnself or herself or through his or hcr own employees. providcd that such inrproverncnts are nol interdcd or offercd for salc. lf. howcwr. the btrilding or inryrrovenrcnt is sold within one ycar of complction. the Owner Buildcr will havc thc burden of proving that hc or she did not build or improve thc proprty for thc purJnse of salc). -1. as owncr of thc profrcrty. am cxclusivcly contracting with licenscd contractors lo construct thc project (Scc. 7M4, Busircss and ltotbsskm Codc: J'he Contractor's Licensc Law does not apply to an owncr of property who builds or improvcs thereon. and who contracts for such pojccts with a Contracto(s) licenscd pursuant to the Contraclor's Liccnsc hw). _l arrr cxcmpt undcr Scrction_. B. & P.C. for this rcason. WORKERS' C OM PEI{SATION DECLARATION I hcrcby affirrn undcr pcnalty of pcrjury onc of thc following dcclarations: _l havc and willmaintain a Ccrtificatc ofConsent to Self-lnsurc for workers'compcnsation, as gnovided for bySection 3700 of the Labor C-ode, for thc pcrfonnancc of the work for which thc permit is issucd. _l havc and will maintain workers' conlpcnsation insurarrcc. as rcquired by Scction 3700 of the labor Codc. for lhe pcrfornurcc of thc work for which this prmit is issucd. My workcrs' comlrcnsation insurancc carricr and plicy nunrbcr arc: )u lr^Trr Poricy *"^*r,t 1 ?4 9l L I Expircs: tD J-B-) I _l certify that in thc Jrcrformance of the work for which this Srcrmit is issucd, I shall not employ any f,crson in any manncr so as to bccomc subjcct to thc workcrs' compensation laws of Califomia, and agrcc that if I should beconrc subjcct to the workers' compcnsation provisions of Section 3700 of the [abor Code. I shall. forthwith comply with thosc provisions. WARNIN(I: Failure lo sccure workers' compensalion covcragc is unlawful. and shall subjcct an employcr to criminal penaltics and civil fincs up to onc hundrcd thousand dollars ($100.00tt), in addition to thc cost of compcnsalion. damages as providcd for the 020\& LICENSED CONTRACTOR NECI.,ARATION I hcrcby affirm under penalty of pcrjury that I am liccrrsed undcr provision of Chapter 9 (comnrcncing with Section 7000) of Division 3 of thc Business and Professions Code, and my liccnse is in full force and effcrct.. t -[oLicensc Class: Liccnse Number:fl7979t Date:-_,. "?- 3-) I Contracto'r W I hcrcby affum urdcr lxnaky of prjury tha thm is I corstructk n lendinS agcrcy for the |Erfol1wc of thc work for shich this lEmit ir issucd (Ss. 3G)7. Civ. C.). hndcr's Nam: [.ender's Address: APPLICAT\TT NECI ARATION I hacby affrm undcr lrcnalty of prjury one of thc following declarations: Dcmolition Pcrmits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40. Part6) -Requircd l-cttcr of Notification -l ccnify th.t thc fucml rcgulations rcgarding asbcstos remval{c mt applicablc to this pmirt. l/fr@f, ,n", I havc rcad this appliqtion ard statc rhat thc atrvc informtion is corcrt. I &gE to @r{,ly with all City and County ordinares and State [2ws rclating to building consrwtiotr ud hcrcby authorire rcpresnt&lircs of this City and County lo cnls upon lhc above mcntioncd proprty for inspcction 'ff')'20 0D^&,7-g-7IApplicant or Agent Sipnature: *Il..r ^. Permitee name (oriinry: K rtr i t I 0 f)onnc t l Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loo r/VenVl ns u latio n Roof Sheathinq Shear Wall Framinq lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat [/asonrv Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif q?D R.^r..l 3-zS-?.t Drrrst4+ FINAL &tx*zt latsP{r. Certificate of Occupancy Notes, Remarks, Etc. Rev. OB-07 -201 5