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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE !D/SIG COMMENTS OWNER BUILDER DELCARATION <br />I hqcby 8ffm und6 poalty of pqjury that I m exmpt from th€ ContnctoE' Licre law for thc followirg r@tr (Se.7031.5 <br />Buins md Prcf*ion Codc): Any City or County which rcquirc a pcmit to co]lltruct, altq. improvc, dsmlth or rpair $y <br />struciue, prior to its isswcc, aho rcquic thc qplicet for such pcrnit to filc a signcd srrrmot thd hc or slE b licosrd pueaot <br />to thc Fovisiom of thc Contrrctor's Liccnscd t:w (Chaptq 9, Com@cing with Setion 7000 of Division 3 of thc BNin* ud <br />PrcfcsioB Codc) or thrt hc or shc ie cxmpt thqr&om md thc bosis for thc sllcgcd q@p(ion. Any violstion of Scrion 7031.5 by uy <br />applicutforapcrmitsubjetsthc spplimttoacivilpmltyofnotmorcthnfivchmdreddollm($500). <br />_1. s ownq of thc popqty, or my employG with wag6 I their mlc ompcruaion" wil do thc w* ed thc stnrdw b rct <br />intqdcd or offard for slc (Se.7044, BGins ed kofcssioN Codc: Thc Contractor's Licre t w do6 not apply to e owq of <br />thc popoty who builds or imFovc tluon, ad who do6 reh wrt himsclf or harlf or through his or ha oM mployce. <br />prcvidcd that such improwts e rct intodcd or ofErod for slc. If. howrc. thc building ot imgovcmt is $H within onc )qr <br />of ompldiort thc Osn6 Build6 will havc thc h[d6 of prcving tlra hc or shc did mt tuild or imprcvc thc propdy 61 0E prpo$ of <br />slc). <br />-1, <br />r oma of thc propoty, m ucluivcly contrrcting with licaacd contradoE to @rotruct the prcj*t (Se. 7044, Buine <br />ud Profcsim Codc: Thc Contnctor's LiccNc Law doe not spply to m owna of prcpoty who builds or imprcv€ ths@n, <br />md who ontrrc{s for such projcts with a Contraao(s) licascd pmwt to thc Contrctor's Licw lrw). <br />-l <br />m cxcmpt udfi sction-, B. & P.C. for this rwn. <br />I)o lo' <br />WORKEITS' COMPENSATION <br />DECI.ARATION <br />I hereby allirm under penalty of perjury one of the following declarations: <br />_l have and will maintain a Certificate of Consent to SelFlnsurc for workers' compmsation, as provided for by Soction 3700 of the <br />Labor Codc, for the performancc of thc work for which thc pcrrnit is issued. <br />(^:have and will maintain workers'insurance. as by Section 3700 of the Labor Code, for thc pcrformance of <br />and policy numh are:work for which this pennit is issuetl.ciuTler <br />Policy <br />_l ccrti& that in the pcrformance of the work for which this pcrmit is issued. I shall not cmploy any pcrson in any manner <br />so as to becomc subject to the work€rs'compcnsation laws of California. and agree that if I should become subject to the <br />workers' compensation provisions of Section 3700 of the kbor Code. I shall. forthwith comply with those provisions. <br />WARNTNG: Failure to secure workers' comperration coverage is unlawful, and shall subject an onployer to criminal ponltics and <br />civil fines up to one hundred thousand dollars ($100,000). in addition to the co$ of compcnsation, damages as provided for the <br />Section 3076 of the l-abor Code interest and attorney's <br />r-l <br />DI'CT,AITAI'ION <br />I hcreby aflirm under paralty of perjury that I am licenscd under provision of Chapter 9 (comrncncing with Section 7000) of Division 3 <br />of thc Business and Profcssions Code, and my license is in full force and effect. <br />Liccnse -r> <br />W <br />I heEby affm udq pqElty of pcrjury that th@ is 8 @$truction Lrding ag6cy for thc pqfoffic of thc mrt for which this psmil b <br />issued (Sc. 3097, Civ. C.). <br />Lrnd6's NmG: <br />Lender's Address: <br />APPI ICANT DECLARATION <br />I hcndry alnrm under penalty of perjury one of the following declarations: <br />Demolition Permils-Asbcstos Notification Federal Regulations (Title 40, Parr6) <br />-Required <br />trtter of Notilication <br />_l certi& that thc federal regulations regarding asbestos removal are not applicablc to this project. <br />the <br />above mcntioned property for <br />Applicnnt or Agent <br />Permitec nnmc <br />and state that <br />al <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bfloo r/Ve nUl n su I atio n <br />Roof Sheathing <br />Shear Wall <br />Framing <br />lnsulation/Enerqy <br />Drywal! <br />Ext./lnt. Lath <br />Brown Coat <br />JVlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif ^,Y*r_fur (Z \ ,i\\(\/ a'-I _C,n, <br />FINAL ,/ <br />/\o /-y \,4 <br />Gertificate of Occupancy / <br />Notes. Remarks, Etc. <br />-2- <br />oare:/6 fr; f C I