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SITE-WORK DATE ID/SIG COMMENTS Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/Ve nUl n s u latio n Roof Sheathing Shear Wall Framing lnsulatio nlEnerqy Drywall Ext./lnt. Lath Brown Coat Jvlasonry / Pool Fence T-Bar \ Handicap Req.\ Deputy Final Report Engineer Final Report / Flood Zone Certif . FINAL ro\5\,ra _\N.n'o \ Certificate of Notes, Remarks, Etc. \ --J \ / I hercby affrm undcr Fnalty of Frjury that I m cxcmpt ftom thc Contraclor' Liccns lrw for thc following rcasn (5â‚¬.7031.5 Busincss und Profcssion Codc): Any City or County which rcquircs a pcrmit lo @nstruct. sltq, improve, dcmlish or rcpair any structure, prior lo its issuancc. ds rcquircs thc applicml for such lrcmit to lih a signcd statcmnl lhat hc or she is licensd pusuol lo thc provisions of the Conlractor's Liensd tiw (Chapter 9, Comcrcing with Scctiotr 7000 of Division 3 of ttE Busircss eg PmfcssionsCodc)orthatheorshciscxcmptthercfromsndthcb&sisfo.thcollcgcdcxcmption. AnyviolationofscctionTO3l.5byany applicant for a pcmil subjetts the applicant to a civil pcnahy of not mrc than fivc hundrcd dolles ($5m). _1. as owncr of thc proprty. or nry employccs with wagcs as their solc conrpcnsation. willdo thc work and thc structurc is not intendcd or offcrcd for salc (Scc.7044. Business and Profcssions Codc: The Contractor's License [:w docs not apply to an owncr of thc propcrty who builds or improvcs thcrcon. and who docs such wo* hirnsclf or hcrself or through his or hcr own employces. provrdcd that such improvenrcnts are not intcndcd or oflcrcd for salc. lf, howevcr, thc building or improvcnrcnt is soH within one )rcar of comphtion. thc Owner Buildcr will have thc burdcn of proving that hc or she did not build or improve thc prcpo'ty for thc purprsc of salc). -1. as owncr of thc proprty, am cxclusively contracting with liccnsed contractors lo construct thc projcct (Sec. 7W. Busincss and hofcssion Codc: Thc Contractor's Liccnse Law docs not apply to an owncr of propcrty who builds or improves thcrcon, and who contracts for such projccts with a Contractor(s) liccnsed pursuant to thc Contractor's Liccnsc kw). -IamcxemptundcrScction-.B.&P.C.forthisrcason. }VORK I.'RS' CONI PUNSA'tION DECLAITATI(IN I hercby affirm under pcnaltyofpcrjury om ofthe followhg delffations: -lhavcardwillmintainaCcrtiticalcofConsnttoSclf-lnsureforworkem'com;rcnution,as povidedforbySetion3?00ofthc Labor Codc, for thc prformrcc of thc mrk for which thc pmit is issucd. .Lt havc ona will maintain workcs' compcnsation insurarcc. as rcquircd by S$tion 3?00 of thc bbor Codc, for thc pcrformrcc of thc work for which this pcmit is issucd. My workc6' @mJrcnstion insurarcc cmicr axl policy number ac: Av.-or, rr^,^ ?:n rh Poricy*r^*r,44-)Qcl?1OO Expires: -l ccrtily that in thc pcrfornuncc of thc work for which this pcrmit is issucd, I shall not cmploy any pcrson in any manncr so as lo beconrc subjcct to lhe workcrs' compcnsalion laws of California. and agree that if I should bccomc subicl to thc workcrs' compcnsation provisions of Scction 3700 of the latnr Codc. I shall, forthwith comply with thosc provisions. WARNING: Failure to sccurc workcrs'conrpcnsation covcrage is unlawful, and shall subjcct an cnrploycr to crirninal pcnaltics and civil fines up to onc hundrcd thousand dollars (S100.000). in addition to thc cost of compcnsation, danragcs as provided for the Scction 3076 of thc Lahrr Code. interest and attorncy's fccs. r<L I hereby allirrrr undcr pcnalty of pcrjury that I anr liccnscd of thc Busincss and Profcssions Code. and rny liccnsc is provision of Chaptcr 9 (comrrrcncing with Scction 7000) of Division 3 forcc and cffcct. ctorr, CIO LicenscNumbcr:l0)Jo" a 0 I)ate:tslt*lzt contracto r, NOwrrr-rllrrn'r, SOl cul1l W I hcrcby affirm undcr Fnalty of pcrjury that thcrc is a @nstruction bnding agcrcy for thc pcrfomncc of thc work for which this lEmit is issucd (Scc. 3097. Civ. C.). [rndcr's Narc: [.cndcr's Addrcss: APPLICANT DECLARATION I hcreby affinn undcr pcnalty of pcrjury one of thc following declarations: Dcmolition Permits-Asbcstos Notification Federal Rcgulations (Titlc 40. Part6) _Requircd lrttcr of Notification -l ccrtily that thc fedcral rcgulations rcgarding asbcstos renxrvaliuc rx)t applicablc lo this projcct. ccrtify lhat I havc rcad this application and statc that and State Laws rclating to building above mcntioned propcrty for or Agent Pentritee nanle lk 1-J BUILDING- INSPECTOR RECORD ! t t Date:_Owner: ^ bu ltt- bun^cV^