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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION <br />I hoc$l afum und6 paalty of psjury that I m qmpt fiom thc Contrs.lon' Licre law for thc followiag rwn (Sc.7031.5 <br />Buins and hofeion Codc): Atry City or County which rcquim a pumit to coEtruct, sltq, isprovq daaolish or npair my <br />struclue, Fior to it3 ismcc, also rcquire thc ryplicet for such pcnrit to filc E signcd statmot thd hc or shc b licasrd plmst <br />to thc prcvisioru of thc Conractor's Limcd law (Ch4tq 9. Commcing with Sction 7000 of Division 3 of the Buine md <br />PrcfeiomCodc)orthathcorshcisq@ptthqc&omedthcbosisforthcallcgcdaoption. AnyviolationofS€rion703l.5byey <br />applicet for a psmit subjets the applic&t to a civil pcnalty of not more thd fivc hundred dollus (S500). <br />_1, s oma of thc Fop6ty, or my mplolc with wag6 a thcir slc @mpsMtioo, will & thc wr* ad tlE srrudrc b mt <br />intqrdod or ofiqed for salc (Sa.7044, BEins ud ProfsioN Codq The Conlmctor's Licffi trw do6 not apply to u oMs of <br />rhcFopqty whohrildsorimprorcttuocsdwhodo6zuchwr*hiwlforhelforthrcughhisorhqommploye, <br />providcd that such improffits rc mt intqrdcd or ofu for slc. lf, trcw, thc hiHhg or inprovmt is sld within onc )qr <br />of compl*bn thc oluao BuikLr wil lurc thc hrd6 of poving tha hc or strc did mt huiH or inprovc thc popaty br thc prpos of <br />sdc). <br />-1. <br />I oMq of thc propqty. m cxcluivcly coilmcling with lic@s.d contrutoB to coctrud tlrc Fojet (Se. 7044. BNinB <br />and Profcsim Codc: Thc Contrctor's Licdsc Law do6 not apply to e own6 of prcpcrty who builds or imprcvG thq@o, <br />md who coolracls for such prcjcts with 8 ConEaclo(s) licascd punuant to thc Confactor's Licre hw). <br />_l am under Section-. B. & P.C. for this rcason. <br />I hereby affrm undcr penalty of pojury one of the following declarations: <br />_l have and will maintain a Certificate of Consext to Self-lnsure for workers' compensation, as provided for by Section 3700 of the <br />Labor Code, for the p€rfonnancc of the work for which thc pcnnit is issued. <br />_l have and will maintain workers' compensation insurancc. as required by Section 3700 of the L^abor Code. for thc performancc of <br />the work for rvhich this permit is issued. My workers' compensation insurance carricr and policy number are: <br />{ <br />_l certi$ that in the performance of the work for which this permit is issued, I shall not employ any p€rson in any manner <br />so as to bccornc subject to the workers' compensation laws of California, and agrce that if I should become subject to thc <br />workcrs' compensation provisions of Section 3700 of the kbor Code I shall. forthwith comply with those provisions. <br />WARNING: Failure to secure workers' compemation coverage is unlawful, and shall subject an employer to criminal poulties and <br />civil fines up to one hundred thousand dollars ($100.000). in addition to the cost of compensation, damages as provided for the <br />Section 3076 of the l-abor Code, interest and attorney's fees. <br />DECI,ARATION <br />I hereby affurn under penalty of perjury that I arn licenscd undcr provision of Chapter 9 (cornmencing with Section 7000) of Division 3 <br />of the Business and Professions Code, and rny license is in full force and effect. <br />License Class: License Number: <br />Contrrctor: <br />W <br />I ha$y alhm undo pqdty of psjury rhd thc is a @n$rucliotr lading agmy for thc psforocc of thc wrk for which this pqtnh b <br />isucd (Sc. 3097, Civ. C.). <br />I-cnder's Namc: <br />lender's Addrcss: <br />APPLICANT NECLARATION <br />I h€rcby affirm under penalty of perjury one of the following declarations: <br />Demolition Perrnits-Asbestos Notification Fcderal Regulations (Title 40, Part6) <br />-Required <br />lrtter of Notification <br />-l <br />cdiry that thc fcddal tcgulatioro rcgading ubatos r@oval ac not appliceble to this proj61. <br />_l cdiry that I havc rcad this application and statc thal thc abovc inforrralion is corot. I agre to @mply with 8tl City ed County <br />ordimcG ed Statc lrs rchting to building coDgruclion, ad h@by authorizc rc?rBqrtarivc of this City md Couty to otq upoo thc <br />above mentioned property for irspection <br />Applicant or Agent <br />l'ermitee nRme <br />Dric ltulL{ <br />Set Backs <br />Forms/Stee!/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bfloor/Ve nUl n s u Iation I t I <br />Roof Sheathinq 0 \q0\1L vwy I / <br />Shear Wall rl / <br />Framing <br />Insulation/Enerqy <br />Drynrvall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Fina! Report <br />Engineer Final Report <br />Flood Zone Certif <br />t .A e I <br />FINAL l\q\7/\ulr{6 <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />Policy Numbcr: Expires: <br />UtYr.aaq€ f^/C"h8f'tLlrt <br />rl