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BUILDING. INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATTON <br />I hccby affrm unde pcnalty of pcrjury that t m cxcmpt 6om thc ConracloB' LiccN lrw for thc following lten (Se.7031.5 <br />BGins md Profsion Code): Any City or County which rcquirs a p6nit to coNtruclr altq, improvq danolish or rcpair my <br />strucluc. prior to its issumcc, aho rcquire thc applicilr for such pamit to filc a sigtrcd ststmot tha hc or shc b licoscd pmmt <br />to the Eovisions ofthe Contrrctor's Liccnsed taw (Chaptq 9, Commcncing with Setion 7000 of Division 3 ofrhe Busins md r <br />Prcfcssions Codc) or that hc or shc is cxmpt thqcfrom ed the basis for the allcgcd cxopion. Any violation of Setion 703 I .5 by my <br />ffi ;-;#ffiffiffi;;;*ffi*,**********", <br />thc prcIsty who buil& or improvc thqor\ ild who doe srch mrk himself or helf or tluough his or ha om mployes. <br />provided rhat such imlrcvffits rc not itrtqrdcd or offqql for slc. lf, howds, thc building or irwovcrmt is $ld withir onc )@ <br />ofomplaion, the Owno Buiklr will harc thc hrdqr ofproving tlra hc or shc did mt build or improrc thc propoty 6r thc pupor of <br />sle). <br />_-1. as owner of the property, am exclusively contracting with licensed contractors to construct the project (Scc. 7044. Busincss <br />and hoftssbn Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, <br />and who contracts for such projects with a Contracto(s) licensed pursuant to thc Contractor's License l-aw). <br />_l am B. & P.C. <br />{LI <br />DECLARATION <br />I hereby affinn under penalty of perjury one of the following declarations: <br />-l <br />have and will maintain a Cerlificate of Consent to Self-lnsure for workers' compensation. as provided for by Scction 3700 of the <br />labor Code, for the performancc of thc work for which the permit is issued. <br />-l <br />have and will maintain workers' compensation insurance. as required by Section 3700 of the labor Code, for the performancc of <br />the work for which this permit is issued. My workers' compensation insurance carrier and policy numbcr are: <br />A <br />Policv Nurnbcr' <br />br...riryrno, <br />_Expires: <br />in the performancc of the rvork for which this pcrmit is issued. I shall not employ any pcrson in any manner <br />so as to becorne subject to the workers' compensation laws of California, and agree that if I should become subject to the <br />rvorkers' compensation provisions of Section 3700 of the Labor Code, I shall. forthrvith comply with those provisions. <br />WARNING: Failurc to scrure workers' compensation coverage is unlawful, and shall subject an employer to criminal pcnalties and <br />civil fines up to one thousand dollars ($100,000), in addition to the of compensation.for the <br />Section 3076 of the interest and attorney's fees. <br />(t <br />DECLARATION <br />I hereby affrm under penalty of perjury that I arn licensed under provision of Chapter 9 (commencing with Section 7000) of Division 3 <br />of the Business and Professions Codc, and my license is in full force and effect. <br />License Class: License Number: <br />CONSTRUCTION LENDING AGENCY <br />there is a construction lending agency for the performance of the work for which this perrnit is <br />Lcnder's Addrcss: <br />APPLICANT DECLARATION <br />I hereby affrrn under penalty of perjury one of the following declarations: <br />Demolition Permits-Asbestos Notilication Federal Regulations (Title 40, Part6) <br />-Required <br />lrtter of Notification <br />I certifo that the <br />E*irytr,u, I have <br />fbderal regulations regarding asbcstos removalare not applicable to this projcct. <br />read this application and state that the above infonnation with all City and <br />ordinances and State Laws relating to upon the <br />above mentioned propcrry for <br />\tppticant or Agent <br />Permitet' nanlc (print): <br />and to <br />ZI <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bfloor/Ve nUI n s u latio n <br />Roof Sheathins <br />Shear Wall <br />Framincl <br />lnsulation/Energy <br />Dnnryall <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 <br />Flood Zone Certif. <br />II <br />FINAL Clzthr {4C JK <br />Certificate of Occu pancy I <br />Notes, Remarks, Etc.,A\ <br />cd 1-/P',-e <br />{ <br />A <br />Carrier:_ <br />! <br />f!^-. <br />-^ ^a ^-, <br />issued 3097. Civ. C.). <br />Name: <br />t <br />a <br />I