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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DE1CARATION <br />I haeby affm undq pqElty of perjury thar I m cxcmpt ftom the Contrac{oB' Licre lrw for thc following rcen (Sc.7031.5 <br />Buincs ard Prcfcsion Codc): Any City or Couty which rcquirs a pomit to condruct, altq, imprcvc donolish or rpair py <br />struc{we. prior to its hswcc, also requirG thc applicst for such pqrnit to 6lc a signcd stamat that h€ or slrc is licq$d ptNut <br />to thc provisioN ofthc Contrador's Licens€d trw (Chaptd 9, Commmcing with Sction 7000 ofDivision 3 ofthc Buin* m{ <br />Profsions Codc) or that hc or shc is cxcmpt thscfrom ed thc basis for thc allcged aoption. Any violation of Sstion ?03 I .5 by a;i <br />applicmtforapmirsubjctsthe applicmttoacivilpoaltyofnotmorcthufivchun&cddoltm($500). <br />_1, 6 own6 of thc propetly, or my mplo)6 with wag6 a thcL $lc ompcrEation, will do dE wuk and dE srnErrc b mt <br />intmdcd or offced for sle (56.7044. Buitrs ad PrcfsioN Codq Thc Contmclor's LicGN L8w do6 not apply to e oM6 of <br />thc popqry who builds or improvc tlu@tr and who do6 such rcrt himsclf or hemlf or thrcugh his or h6 om mployc. <br />providcd that such impromts rc not intqdcd or offqcd 6r sh. I[ howq, tlE tuiHing or imp(ovmt is sld within onc ]qr <br />ofcompldiorl thc Own6 Buikk wil harc tlrc hrdo ofproving tha he or shc did not hriH or imprcw thc propqty for thc puporc of <br />elc). <br />-1. <br />o omq of the prcpqty. m cxclsivcly contrac{ing with licGcd contractoE to onstruct th€ prcjet (SE. 7044, B6ios <br />and Profosbn Codc: Thc Contretor's Liccme Law do6 not apply to m owncr of property who builds or imprcvs th66n, <br />and who contrac{s for such projsts with a ContEcto(s) licqts€d pffiuut to thc Contrac{or's Licffi Law). <br />-l <br />am exempt under Section-. B. & P.C. for this reason. <br />Owner: <br />WORIGRS'COMPENSATIM <br />DECLARATION <br />one of the following declarations:I hereby aflirm under penalty of perjury <br />-l <br />have and will maintain a Cenificate of Consext to Self-lnsure for workers' compensation, as provided for by Section 3700 of the <br />Labor Code, for the performance of the work for which the perrnit is issued. <br />\t r,"r" <br />the work <br />and rvill maintain Section 3700 of the labor Code, for the performancc of <br />rvhich this carrier and policy numh are: <br />ZLPolicy-?-7: <br />_l certity 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 bc.come subject to thc workers'compensation laws of California, and agrce that if I should bccome subject to the <br />workers' compensation provisions of Se'ction 3700 of the l-abor Code. I shall. forthwith comply with thosc provisions. <br />WARNTNG: Failure to sccure workers' compensation coverage is unlawful. and shall subject an onployer to criminal penalties and <br />civil fines up to one hundred thousand dollars ($100.000). in addition to the cost of compcnsation, damages as provided for the <br />Section 1076 of the Labor Codc, interest and attorney's fees. <br />,*", 8*zLl -z( <br />I hcreby affrrm undcr penalty of perjury that I zun licenscd 9 (commencing rvith Section 7000) of Division 3 <br />of the Business and Professions Code, and my license is in full force and effect. <br />License Class: License Number: <br />W <br />I hscby affum undq pmlty of psjury that th6e is a constructbn hnding ag6cy for thc pcfomce of the work for which this pqmh b <br />issucd (Se. 3097, Civ. C.). <br />Lender's Nanre: <br />I-cnder's Ad&ess: <br />APPLTCANT DEC LATTATION <br />I hoeby aflinn under penalty of perjury one of the following declarations: <br />Demolition Perrnits-Asbestos Notification Fedcral Regulations (Title 40. Pan6) <br />,( **ned Later of Notification <br />Kt "otitythat the lderal regulations reBarding asbcstos rernoval are not applicable to this projecl. <br />with all City and County <br />and County to enter upon the <br />above mentioncd property for <br />Applicant or Agent <br />hercby <br />Permilec nanre <br />to <br />tlrat is <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bfloor/Ve nul nsu latio n <br />Roof Sheathing <br />Shear Wall <br />Framing <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />lt <br />FINAL LO lrrt )sfid|; <br />Certificate of Occu pancy <br />Notes, Remarks, Etc. <br />-/