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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE !D/SIG COMMENTS OWNER BUILDER DE1CARATION <br />I hocby affm undo pcnalty of po'juy that I m excmpt from thc ContractoB' Licw liw for thc following @n (Sc.7031.5 <br />Bwincs and Profsion Codc): Any City or County which rcquire a po'mit to coEtruct, altq, imprcv_c &molish or rpat oy <br />sructue, prior to its iswcq also rcquic thc applimt for such pcnnit to frlc a sigtrcd staimqt thd t€G stE b licqucd prmilt <br />to thc prcvisioro of th€ Contrctor's Licms€d taw (Chapt6 9, Commcncing with Setion 7000 of Divirion 3 of thc Buincs ud <br />Prcfcsions Codc) or that hc or shc is qcmpt thscfrom ad rhc basis for thc allclcd cxmption. Any violBtion of SEtioo 7031.5 by ey <br />applicant for a pcrmit subjcts thc applic$t to a civil pmlty of rct morc tho fivc hundrcd dollm ($500). <br />-L <br />c omq of thc prcpc(y, or my cmployG with wagB I thcir rclc compcruation, will do thc wort dd thc $tuctrc is not <br />intqdcd or olfscd for salc (Se.7044, B6ins md Profeiom Codc: Thc Conraclor's LiccE Law do6 rct apply to u omcr of <br />thc Dropsty who hrilds or imptoc tllqot ad who doc sEh wrt himsclf or hwlf or thrcugh his or ho om mploycc, <br />providcd that such imFoEnals rc rct htqrdod or offqrd for sb, lf. hoM. thc hiHing or imtromt is sH vithin onc )qr <br />of complaion, thc otrnq Buildq will havc thc h[dor of troviry thd hc or shc dil mt build or irprovc Ihc propqty for tbc p[pos of <br />slc). <br />-1. <br />as owner of the prop€rty, am exclusivcly contracting with licenscd contractors to construct thc project (Sec. 7044, Brsincss <br />and holission Code: The Contractor's License Law does not apply to an owner of propcrty rvho builds or improves thereon, <br />and who contracts for such p,rojects with a Contracto(s) licersed pursuant to thc Contractor's License Law). <br />-l <br />am exempt undcr Section-, B. & P.C. for this reason. <br />flqlo' <br />WO RKER^S' COMPENSATION <br />DECLA,RATION <br />I hcrcby affrm undcr perialty of pcrjury onc of the following declarations: <br />-I <br />have and will maintain a Certificate of Consent to Self-lnsure for workcrs'compensation, as provided for by Secrion 3700 of the <br />Labor Codc, for the pcrformance of thc work for which thc pcrrnit is issucd. <br />-l <br />have and will maintain workers' compcruiation insurance. as requircd by Section 3700 of the l^abor Codc, for thc performance of <br />the work for which this permit is issued. My workers' compensation insurance carrier and policy numhr ine: <br />0 !^^ > <br />Poricyx,r^w, , 1,L9u1 9ol -at Expire*C)) - LL <br />-l <br />ceni& that in the performance of the work for which this permit is issued, I shall not employ any person in any manner <br />so as to become subjet to the workers' compensalion laws of California, and agrec that if I should become subject to the <br />workers' compcnsation provisions of Section 3700 of the l-abor Code I strall. forthwith comply with thosc provisions. <br />WARNING: Failure to securc workers' compensation covcrage is unlawful. and shall subject an onployer to criminal penalties and <br />compensation, damages as provided for thecivil fines up to one hundred thousand dollars ($100,000), in 'ru"'Section 3076 of the Labor Codc, intcrest and <br />i"1u. 4?-. L-l a Z t <br />I hcreby affrm under penalty of pcrjury that I am licensed 9 (cornmancing with Section 7000) of Division 3 <br />of the Business and Professions Codc, and my license is in full force and effect. <br />License <br />) L'9 ?Y Y? <br />o*e: od[z?-4 ' U <br />W <br />I h*by affm undo pcoalty of pqjwy thal thsc is a @ostructbtr knditrg sg@cy for thc pqfomcc of thc wrk for which this pqmit b <br />isucd (Se. 3097, Civ. C.). <br />Lender's Name: <br />a <br />I-codcr's Ad&ess: <br />APPLICANT DECLARATION <br />I herdry aflirrn under penalty of perjury one of the following declarations: <br />Demolition Permits-Asbestos Notification Federal Regulations (Title 40. Part6) <br />-Rcquired <br />Lrtter of Notification <br />J <br />-l <br />certifi that the Heral regulations regarding asbestos rcmoval iue not applicable to this project. <br />-l <br />cctiry that I havc r€d this applicatiotr ed statc that thc abovc infomation is concl. I agrc to comply with all City and County <br />ordimncBlnd Statc trws rclaing to building comtruc{ion, ild hdeby authoriz repr6dtativc of this City od Counry to atq upon thc <br />above motioned prcpoty for ireparion purpos. <br />Applicant or Agent {.- \a;. <br />Pernrilee nRme <br />I <br />f(t <br />L , <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bfloor/Venul n su lation <br />Roof Sheathing 7-28-Lt a--{ t+2 <br />Shear Wall <br />Framing <br />lnsulation/Energy <br />Drywal! <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 />FINAL 6-f-A.t >--e, {r- <br />Gertificate of Occupancy <br />Notes, Remarks, Etc. <br />n