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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUTLDER DETARATION <br />I hqehy affm undc pcnalty of pojury thrt I m cxcmpt ftom thc ContncloB' Licre lrw for thc following @n (Se.7031,5 <br />Buins ad Profsion Code): Atry City or County which roquire a pcrnit to @mtrucl altq, improvg danolish or rcpair ay <br />sructurq Fior to its ismcq also rcquic thc +plicut for such pqnit to filc s signcd stalmat thd hc or drc b licqEcd pllMt ' <br />to thc provisioE of thc Coilretor's Liccnscd hw (Chsptq 9, Comcrciog with Setion 7000 of Division 3 of thc Buirc ud <br />PrcfsioB Codc) or that hc or shc b qopt thq!&om md thc basb for thc allcgcd amptioo. Any viobtion of Sdbtr 7031.5 by oy <br />epplicut for a pcmit subjets thc applimt to a civil pcmlty of rot morc the frve hundrcd dotlas ($500). <br />-1, <br />c omc ofthc pmperly, or my cmplo)6 with w8g6I thcir slc @mpcNrion. will do th€ wort and thc stndE is not <br />intqrdcd or offcred for slc (Sc.7044. Buins md Prcfeiore Codc: Thc Contraclor's Licffi la doc not 4ply to u oms of <br />thc Fppcty who huilds or irprove ttE@n sd who do6 reh wrt himrlf or helf or thrcugh hB or h6 om mployce, <br />prcvidcd that such imFomr @ mt intqdrd orolH for slc. lf, lrcw, tlrc hilding or inprcvsmil is $H within onc )@ <br />of ompktioD, thc Own6 BuiU6 wil harc th€ hrda of prcvig thd hc or shc did et hild or inrprcvc thc popqty for thc Frposc of <br />sdc). <br />-1, <br />I om6 of thc propsty, m crclwivcly cotracting with licqB.d coilmctoE to @Etnrct thc Fojet (Sc. 7044. Bain6 <br />srd PD&sih Codc: Thc Coflrelor's Lic6c law do6 rct apply to s owtr6 of propdy who builds or imprcvB th6on, <br />md who @ntracls for such projEls with a Coilrrclo(s) licoscd puuant to thc Contraclor's Licw law). <br />-l <br />mcxcmpt undo Sction- B. & P.C. forthis Iwn. <br />EABtrEEISOMPINSAIIaN <br />I h@by sffm und6 pq,lty of pqjury onc oC,rc fotlo*inffi <br />/-l^trave at wltt mhtsin I Cdrific{tc of CoMt to SclflBurc for rcrlq' ompsrdion I prcvidcd for by s$liotr 37OO of the <br />' Y;::::[:,'ffi::::ff,:::il *T,Ir,*.",700 0f ,hc rabor codc. fo.hc pqfomcc of <br />thc rcrk for which this pmit is isrcd, My work6' ompcosatioo iromcc mia ard policy numba re:i +^+e o ,-d <br />Policy 0 t /tt lzzII <br />_l certi& that in thc performance of the work for which this permit is issued. I shall not employ any person in any manner <br />so as to home subject <br />workers' compensation <br />to the workeis'compemation laws of California, and agree that if I should become subject to the <br />provisions of Sertion 3700 of the l-abor Code. I shall. forthwith comply rvith thosc provisions. <br />WARNINC: Failure lo secure workers' <br />civil fines up to one hundred thousand <br />and <br />the <br />attorney's fc€. <br />I hoeby affrm und€r penalty of perjury that I am licenscd 9 (commencing with Section 7000) of Division 3 <br />of the Business and Professions Code. and my liccnsc is in full force and effect. <br />o^*, I License Numbcr:///> <br />a L Vv v,/ ol <br />W <br />t hmby affim undc perulty of pcrjury that th@ is a corutruc,tion bndiry agocy for thc pqfor:mcc of thc rcrk for which this pqrnit is <br />isucd (Se. 3097, Civ. C.). <br />Lcnder's Name: <br />Lcnder's Address: <br />APPLICANT DECLARATION <br />I hatby affirm under penalty of perjury onc of the following declarations: <br />Demolition Permits-Asbestos Notification Federal Regulations (Title 40, Part6) <br />-Required <br />lrtter of Notification <br />.-, <br />certiry that the ftderal regulations regarding asbcstos removal are not applicablc to this project. <br />-l <br />cqtiry thal I havc rad this applietion ad statc that thc above infomation is cotrq1 | .gE to omply with all City ad Couty <br />-ordimcc ad Statc Laws rclatilg to building constructio[ dd hmby authorirc rcprMtaliv6 of this City ed County to ats upon thc <br />above mentioned property for <br />,Nolicent <br />or Agent <br />(ermitee <br />name <br />-0 5 L <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bfloor/Ve nUl ns u latio n <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence V <br />T-Bar \ <br />Handicap Req. <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif. <br />Ir r <br />FINAL \9\Wt-t\vy\r4 7 <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />\ <br />Drte: <br />_ Dete:_