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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DEI,CARATION tI hqew affm undo pcnalty of pcfjury that I m cxmpt fiom thc ContrsctoB' Licffc taw for thc following t@n (Ss.7oil <br />BBins ild hofsion Codc): Any city or courty which requirB a pqrnit to coNtrucl. alts. inprcvq donolish or rcpoirEry <br />structue Fior to its isuocc. also rcquirc thc applicmt for such psmit to filc a signcd stalmdt thar hc or shc b licqE€d pmuant <br />to the provisiom of th€ Contmtor's Licoscd Law (Chapt6 9, Comcncing with Sctiotr 7000 of Divisioo 3 of thc Buins ud <br />Prcfcsioro Codc) or that hc or shc is amp thccfrom and thc bosis for the allcgcd aopion. Any violation of S€tbn 7011.5 by my <br />applicilt for a pcnnit subj(ts thc applicut to a civil paralty ofnot morc thil fivc hundrcd dollus (1500). <br />_1. I oM6 of thc popcrtn or my cmployc with wagc c thcir rclc compensation, will do thc wort and thc stnrlw is rct <br />intodcd or oftacd for sslc (Sc.7044, BBins md Profsioc Codc: Thc Contractor's LiccN lrw do6 not apply to u omq of <br />rhc prcpgry who huilds or imprcvB thoorl| and who doe sch rcrk hirelf or hcMlf or thrcugh his or ha om oployc. <br />provided that such imprcvmts rc mt intqded or olfqpd for sh. lf. howcE. thc buiEing or impovmt is sH within onc )€r <br />ofcompi*bn, the Own6 Buiklq will hav€ thc hldor ofproving thd hc or she did not bui6 or imprcvc the prcpcty 6r thc purposof <br />elc). <br />-[, <br />m oma ofthe Eopqty, m €xclBivcly contracting with licos€d contractoF to @Ntruct thc projcl (56. 7044, Buine <br />ud Proftsion Code: Th€ Contrrctor's Licere Law do6 not applyto eownq of prcpcrty who builds or imprcvca th6@n, <br />md who @ntBcts for such pmjets with I Contreto(s) licoscd purcwt to thc Contretor's Liccre Law). <br />_l am exempt under B. & P.C. for this reason. <br />rloto. <br />YOBEESSSAMEENIAIIONpEcldBAIIaN <br />I h@by affm unda poulty of pcjury onc of thc following dclantiom: <br />-l <br />havc urd will mintain a Cqtifrcatc of Cotlffit to Sdf-lNre for workc' ompcnsation, r providcd for by Selion 3700 of thc Itabor Codc, for thc psfomcc of thc rcrh for which thc pqmit b isucd. <br />Y6 fruu" and will maintain workers' compcnsation insurance, as required by Section 3700 of the L:bor Code. for thc perfonnance of <br />the work for which this pcrmit is issued. My workers' compensation insurance carricr and policy numhr are:I <br />Policy NL c,r- o C..ZL <br />_l certi& that in the perforrnance of the work for which this permit is issued, I shall not qnploy any person in any manner <br />so ns to become subject to the workers' compensation laws of California. and agrec that if I should bccome subject to the <br />workers' compensation provisions of Section 3700 of the Labor Code, I shall. forthwith comply with thosc provisions. <br />WARNING: Failure to secure workers' compensation coverage is unlawful. and shall subject an anployer to criminal penalties and <br />civil fines up to one hundred thousand dollars ($100.000). in addition to the cost of compcnsation, damages as provided for the <br />Section 3076 of the Labor Code. interest and attorney's fees. <br />o*u, 0Q-04-?t <br />DECI"ARATION <br />I hereby affrm under penalty of perjury that I am licensed under provision of Chapto 9 (commencing with Scction 7000) of Division 3 <br />of the Business and Professions Code, and my license is in full force and effcct. <br />License Nurnber:t'o 7 o sll <br />o*e: OQ- OQ - ? I PP oTe c'rt eEtL CcrvtTPt'crt'o/L) <br />W <br />I hseby affm undcr pqulty of perjury that thm is a comtruction hnding agocy for thc paforrmcc of thc mrl for which this pqmit is <br />issued (Sa. 3097, Civ. C.). <br />[f,ndq's Nmc: <br />Lender's Address: <br />AfITJCANIIECI.ABAIION <br />I ho*y affim undr poalty of pcrjury onc of thc followhg dalratiou: <br />D@olition Pmit$Asb6tos Notification Fcdsal RcgulatioN (Titlc 40, Part6) <br />-RcquLed <br />Lctts of Notification <br />-t <br />cdiry thal thc fcdcal rcXulatiore rcaarding sbetos moval e not applicablc to thb prcjel. <br />Et ,rti* tt. l hrvc ud this application and st8tc thal thc abovc informarion is cor€l. I agrc lo omply with 8ll Cily ud County <br />'ordimcc md State Laws rching to building consruction ad lEcby authorirc rcF€atrliv6 of this City od Couty to 6tc upotr thc <br />above mentioned property for inspection <br />Applicant or Agent o*e: 4-o ?- 2/ <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bfloor/Ve nUl n su I atio n <br />Roof Sheathing <br />Shear Wall <br />Framinq <br />lnsulation/Energy <br />Drurvall <br />Ext./lnt. Lath <br />Brown Coat <br />Nlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Fina! Report <br />Enqineer Final Report <br />Flood Zone Certif. <br />Ir , <br />FINAL a wA?\ <br />Gertificate of Occupancy I <br />Notes, Remarks, Etc.n I <br />4 <br />I <br />Pernritee name (print):_ <br />b\A({ry