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BUILDING. INSPECTOR RECORD SITE.WORK DATE IDiSIG COMMENTS Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfl oo rA/e nUl n s u I atio n Roof Sheathinq Shear Wall Framing lnsulation/Enerqy Drlnrvall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Fina! Report Flood Zone Certif IFINAL Ttr SuPtN 2 I (r, lWrt Cdtrt'l l"ol ,)R Certificate of Occupancy I I Notes, Remarks, Etc. t rraclry affr,'furrr paalty of pcrjury that ,t#X*?lk"J,["'a1Yrtffifto,lr* ** for thc foltowing r@n (s6.?03t.5 8Ein6s ild Prof6sion Code): Any City or County which rcquirG 8 p6mit to coNtruct, altc, imprcvq danolish or rcpat my structuc. prior to its isuucc, also rcquirc thc applicmt for such pcnril to 6le I signcd st8tmot that hc or drc k licoscd pul3wt to thc provisiom of thc Contractor's Liccnscd lxw (Chapt6 9, Commcing with Setion ?000 of Division 3 of thc B$ins ild Prcfmiom Codc) or that he or she b cxcmpt thqcfrom ild thc basis for thc allcgcd q@Bion. Any violation of Sction 7031.5 by any lppliciltforapcnnitsubjetsthc applienttoacivilpoaltyofnotmorcth&Iivchundrtddollm($500). -1, 6 omd of the prcpedy, or my mployc with wage r thw elc ampcmtion, will do rhc wort ed thc atnrtrc is not intmded or ofIered for ele (Sc.7044, Bwins ild Prof*ioro Codc: Thc Contractor's Liccre Law doe not apply to il oms of the propcrty who builds or im1rcrc thqo& ed who do6 sh wr* himself or hmclf or thrcugh his or ho om mploye, provided that such imptovmts rc mt irtodod orolfcrod for sle. I[ howm, thc building or improvqn@t is rcld within onc ]an ofcompldion thcOwnsBuildqwi[havcthchrdorofprovingthalhcor$cdilrctbuildorimprovcthctrDpqtybrthâ‚¬puposof slc). _1, I omq of thc propoty. m cxclusivcly contrscting with licqEcd contractoE to onstrud the Fojel (Se. 7044, BusinN od ProfosimCodc:TheContrrctor'sLiccn$kwdo6notapplytomownqofpropcrtywhobuildsorimprcvethqsn. and who comracts for such fojats with a Contraao(s) licoscd pmwt lo thc Contractor's Licâ‚¬e Law). -l m cxempl und6 Sstion-. B. & P,C. forthis rcen. Dete:_ Owner: WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of pcrjury one of thc following declarations: _l havc and will maintain a Certifrcate of Conscnt to Selt-lnsure for workers' compensation. as provided for by Section 3700 of the I-abor Code. for the performance of the work for which the perrnit is issued. _l have and will maintain workers' compensation insurance. as required by Section 3700 of the tabor Code. for the performance of the work for which this permit is issued. My workers' compensation insurance carier and policy number are: I _l cerriD that in the performance of the work for which this pcrmit is issued, I shall not employ any person in any manner so as to become subje<t to the workers'cornpensation laws of California. and agree that if I should become subject to the rvorkers' compensation provisions of Section 3700 of the tabor Code, I shall. forthwilh comply with thosc provisions. WARNING: Failure lo s,ecure workers' compensation is unlawful. and shall subject an employer to criminal penalties and addition to the cost of compensation. damages as provided for thccivil fines up to one hundred thousand dollars ($ Section 1076 of the Labor Code. interest fces.(z- I hereby affirm under penalty of perjury that 9 (comrnencing with Section 7000) of Division .l of the Business and Professions Code, and my license is in full forcc and eflect. License Nurnber:'\"f 3 ? t(p I hereby aflirm under aSency pcrfonnance of the work for which this perrnit is issued (Scc. 3097, Civ. C.). lrnder's Name' Lcnder's Address: APPLICANT DECLARATION i hereby aflinn under penalty of perjury one of the follorving declarations: Dernolition Permits-Asbestos Notification Federal Regulations (Title 40. Part6) .-- -.Required Lctter of Notification _l cerify that the federal regulations regarding asbestos removal are not applicable to this projcct. read this application and statc that the above information is correct. I agree to comply rvith all City and County ordinances relating to building construction. and hereby authorize of this City and County to entcr upon the abovc )Apphcant Pernritee name for -tQ. curr*,- 'tlucctYc+n LlJt tc t- Poricy*,,n* LzUC ftla Q..6 t ) e*pi,es' ? Orte: [\ Qanle I Vqr.?.as