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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hseby affm undq psulty of perjury thal I m cxcmpt ftom the Contrac-to6' Licre law for the following wn (Sc.70i1.5 <br />Buincs ard Prcfcssion Codc): Any City or County which rcquiB a pqmit to corutrucl, altq, improvg danolish or rc?air anf <br />structuq Fior to its issumcc, also rcquirc thc spplicot for such pqmit to filc I signcd stdmot that hc or slrc b licoscd pmt <br />to thc lrovisiore of thc Contmctor's Licmscd lzw (Chapt6 9, Comocing with S$tion 7000 of Division 3 of thc BNitrs ed <br />Prcfsiotrs Codc) or that h€ or shc is cxcmpt thqcfrom ed thc basis for thc allcgcd cxoption. Any violation of Sdion 7031.5 by uy <br />applicant for a pcmit subjets th€ applicut to a civil penally of not more tha five hundrcd dollm ($500). <br />_1, r oms of thc prcpsty, or my cmployca with wagc c their $lc compcru8tiotr. will do thc wrt ed thc stnr-trc b not <br />intqrded or offcred for ele (58.7044, Bsins ud Prof$ioG Codc: The Contractor's Licsc lrw do6 not apply to a omer of <br />thc pmpqty who builds or irnprovc th@n, ed who doe such wrt himsclf or h6clf or ttrough hb or he om cmployce, <br />prcvided that such imprcmmts ec not itrtsd€d or offqcd for s.lc. If, howqq. the building or improwt is sld within onc yw <br />ofcomphtion, thc Owns Buildq will havc thc htrdor ofprovi[8 ttld he or shc did rct build or impove thc popoty for rhc purporc of <br />salc). <br />_1. c omq of thc Fopqty, m cxcluiv.ly conractitrg with liccns€d cotrtracto$ to coNtruct thc projEt (Sa. 7044, Buins <br />ild PrDfsbn Codc: The Contrrctor's Liccmc t w do6 not apply to u ownq of proprrty who builds or improvc thq@n. <br />ed who contnds for such projEls with a Contncto(s) licq&d prc@t to thc Contrsctor's Lic$e t w). <br />-l <br />am cxempt under Section-, B. & P.C. for this reason. <br />Date: <br />WORKERS' COMPENSATION <br />DECLARATION <br />I hereby affirm under penalty of pojury one of the following declarations: <br />_l have and will maintain a Certilrcatc of Consent to Self-lnsure for workers' compcnsation, as provided for by Section 3700 of the <br />I-abor Code, for the performance of the work for which thc pcrmit is issued. <br />_l have and will maintain workers' compensation insurance. as required by Section 3700 of the Labor Code, for the performance of <br />the work for which this permit is issued. My workers' compensation insurance carier and policy numkr are: <br />Policy Number: Expires: <br />-t <br />certify that in the performance of the work for which this permit is not employ any person in any nlanner <br />if I should bc"come subject to the <br />comply rvilh those provisions. <br />and that <br />WARNINC: F'ailure to secure workcrs' cornpensation coverage and shall subject an ernployer to criminal pa,alties and <br />civil fines up to one hundred thousand dollan ($100.000), <br />Section 3076 of the tabor Code, interest and attorney's fees. <br />1o the cost of compensation, damages as providcd for the <br />I hereby alTirm under penalty of perjury that I arn under provision of Chaptcr 9 (commencing with Section 7000) of Division 3 <br />of thc Business and Professions Code, and my licensc is in full force and effect. <br />License <br />l)rrlr.' <br />I hcby affm undo pcoalty of pcrjury that th@ is I corutruciion knding agacy for thc psfor:mcc of thc rcrk for which this pcmit b <br />isucd (So. 3097, Civ. C.). <br />[rnd6's Nm€: <br />l-cnder's Address: <br />APPLICANT DECLARATION <br />I herEbyalfinn under penalty of perjury one of the following declarations: <br />Dcmolition Perrnits-Asbestos Notification Federal Regulations (Tille 40, Part6) <br />_Required Letter of Notification <br />-l <br />certify that the federal regulations <br />-l <br />certify that I have read this with all City and County <br />ordinances and State laws relating to <br />above rnentioned property for <br />Applicant or Agent <br />I'ernrilec nrme <br />removalare not applicable to this projed. <br />and <br />zl <br />upon the <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bfloor/VenUl nsu lation <br />Roof Sheathing <br />Shear Wall <br />Framing <br />Insulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonrv <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif. <br />tr -a <br />F!NAL (e ltt\A D$,44'YY <br />Certificate of Occupancy I <br />Notes, Remarks, Etc. <br />Carricr:_ <br />a <br />Date: <br />Class: <br />and hereby <br />7