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BUILDING. INSPECTOR RECORD <br />S!TE.WORK DATE ID/SIG.COMMENTS OWNER BUTLDER DEI.CARATION <br />I h6cby affm unds pcnalty of pqjury thsr I m qmpt from thc Contrrctos' Liccc [:w for thc following r@n (Sc.7031,5 <br />Buinas and Prcf*ion Codc): Any City or Co6ty which rcquirs a pomit to coretruct, 8ltq, improvc, dmtotish or rcpair my <br />struc1uc. prior to its isuuc, also rcquiG thc applicmt for such pcmit to filc a signcd stalmot thal hc or $c is lic@cd pEuarlt <br />to thc prcvisioru of thc Contretor's Liccnscd law (Ch8pt6 9, Comcncing with Setion 7000 of Division 3 of the Bwinm md <br />PrcfesiomCodc)orthatheorsheisampthqcfromildthcbasbforthcallcscdqmpion. AnyviolationofSetiotrT03l.5byey <br />spplicat for I psmit subjets thc spplicut to a civil pcnslty of not morc the five hundrcd dollm (1500). <br />--1. <br />c omq of thc prcpqty, or my @plo)6 with wsgc I thcir rclc ompquarion, will do dE wort ud thc anrtrc is mt <br />intordcd or offocd for slc (Sc.7M4, B6ine md Profasioro Codc: The Coilretor's Liccrc Law do6 not apply to o ow of <br />thc prcp<ty who builds or improvc th@n, and who do6 $ch m* himself or h€Nlf or thrcugh hb or ha om mploycc. <br />prcvidcd that such imFovmts rc not iiladcd or ofrred for sh. l[ howc. thc buiHing or imprcvmt is sH withia onc ]qr <br />of complaio!, th€ otf,ns Buil& will havc thc h[da of prcving tha hc or she did mt build or inporc thc propqly for thc purpos of <br />sle). <br />-1, <br />6 oms of thc Fopsiy, m cxclsively contracring with lics€d contractoE to coEtrucl tlE projGr (Sa. 7044, BBin6 <br />ud Prohsion Codc: Thc Contmctor's Licmsc Law do6 not apply to a own6 of propqly who builds or improv6 th@n. <br />and who @ntracts for such projets with a Contreto(s) licfficd puBwt to thc Cootractor's Licmc [aw). <br />-l <br />m cxmp unds Setion-, B. & P.C. for this rcmn. <br />Drle _ O*nE' <br />EOBKESS:CAMfINSAIION <br />DECI.ASATJON <br />I hocby affrm unda pdalty of pqjury one of thc following delaratioG: <br />_l have ad will mintain a Cqtificatc of Comt to Sclf-lrourc for workG' compcrEation, c providcd for by Serion 3700 of thc <br />labor Code. for thc pqfolMce of thc work for which thc pqrnit is issucd. <br />-l <br />have and will maintain workers' compensation Section 3700 of the Labor Code, for the pcrformance of <br />the work for which this perfnit is issued.carrier and policy number are: <br />a Cu <br />(\,\)a \Policy <br />-l <br />certift that in the performance of the work for which this pcrmit is issued. I shall not cmploy any person in any manner <br />so as to become subject to the workers'compensation laws of California, and agree that if I should becomc aubject to the <br />workers' compensation provisions of Section 3700 of the Labor Code, I shall, forthwith comply with those provisions. <br />WARNING: Failure to secure workers' compensation is unlawful, and shall subject an to and r <br />thecivil frnes up to one hundred thousand dollars ($addition to the cost <br />Scction 3076 of the tabor Code. interest and attorney's <br />D",., '5-l J--;Ul)\w <br />I hcreby affirm under pcnalty of perjury that I arn licensed provision of Chapter 9 (cornmorcing with Section 7000) of Division 3 <br />of the <br />License <br />Business and Professions Code, and rny license ' <br />i\3 L -,INumber: <br />,",., . s _\)-JlCe\ <br />W <br />I hmby allim undo pcrulty of psjury thst thsc is a coctruclion knding 8g@cy for thc pqfomcc of thc wort for which this pqmit b <br />issucd (Sc. 3097, Civ. C.). <br />Lender's Name: <br />Lender's Address: <br />APPLICANT DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: <br />Demolition Permits-Asbcstos Notification Federal Regulations (Title 40, Part6) <br />_Required Letter of Notification <br />with all City and County <br />and County to eflt€r upon thc <br />Applicnnt or Agent <br />l'ermitee name <br />I )\ <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bfloor/Venul nsu latio n <br />Roof Sheathing <br />Shear Wall ,)Qo ) <br />Framing ;lt\Hav N&t,L) <br />Insulation/Energy l/vt t n <br />Drnrvall 'o//dal :q0 <br />Ext./lnt. Lath I <br />Brown Coat <br />Nlasonry <br />Poo! Fence ,l lt /')G <br />T-Bar /b/,lrfhAr /lDtlt 7%rtr <br />Handicap Req // <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />-'/ /l0 <br />F!NAL IHA/YN- <br />Certificate of Occu <br />Notes, Remarks, Etc. <br />rA <br />.- <br />in lbll <br />Q-l <br />regarding asbestos removalare not applicable to this project. <br />construction" and <br />ffiDTZ