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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I h6cty afrm undq poalty of pcrjury thd I m qf,pt ftom thc Cootraclm' Licw law for thc followiru @tr (Sc.7031.5 <br />Buine md Prcfesion Codc): Any City or County which rcquiro a pcrnit to cooltrucl, alta, improvq damlish or rcpair uy <br />structuc Fbr to its issuocc. also rcquire thc applicut for srch pqmit to 6lc a signcd stdmt thal bc or dE b licas€d plmail <br />to the prcvisioG of thc Contrrctor's Licoscd Law (Chspt6 9. Commcing with Sation 7000 of Division 3 of the Buine ud <br />PrcfesiomCodc)orthathcorshcisdmptthccfromildthcbssisforthcallcgcdamption AnyviolationofSctionT03l.5byey <br />applicutforaperrnitsubjeBthc applicuttoacivilpmaltyofnotmorcthmfivchundrtddollrs($500). <br />-1, <br />s om6 of thc fopcdy, or my cmploys with wagc r thcir $lc @mposatioo, will do thc wrk atd thc stnr{rc is rct <br />iitcdad or otfqcd for salc (Sc.7044, Bsirs od ProfsioE Codc: Thc Conrador's Lic@ law do6 mt 8pply to e owl6 of <br />thcpropgty whobuildsorimpoverhqa&ildwhodo6$chwrthimsclforhwlforthrcughhisorh6ommployc6, <br />providcd that such imFo@t! e rct intqdcd or offqd for ele lf, how. thc buildiag or improvffit L sH within onc )qr <br />of omplrbr\ thc o\vna Buildq will havc thc hrdar of pmving ttra hc or strc did mt hrild or inprovc thc popcty for thc pupo* of <br />$le). <br />_1, r oms of thc prcpqty, m cxclGivcly contracling with liccnscd contrrctoB to @mtruct thc prcj61 (Se. 7044, Bsins <br />and Eoftsix Codc: Thc Contretor's Licmc Law doc rct apply to e own6 of propqty who builds or imprcvB th6oD, <br />and who @dmcts for such projEts with a Contmcro(s) licoscd pummt to thc Contrrctor's Licerc law). <br />I mcxcmDt utrdtr Sction-, B. & P.C. for this rmn. <br />Dete: <br />WORI(ERS' COMPEN SATION <br />DECTARATION <br />I hereby affrrm under poralty of perjury one of the following declarations: <br />_l have and will maintain a Cenificate of Consent to Self-lnsure for workers' compensation, as provided for by Section 37(t0 of the <br />labor Code for the pcrformance of the work for which the pcrrnit b issued. <br />/l <br />the <br />have and will maintain workers'insurance. as by Section 3700 of the l-abor Codc, for the perfonnance of <br />work for which this permit is issued.policy numkr are: <br />Policy <br />_l certi$ that in the pcrformance of the work for which this permit is issued, I shall not employ any person in any manner <br />so ,ts to become subject to the workers'compensation laws of California, and agree that if I should become subject to the <br />workers' compensation provisions of Sedion 3700 of thc tabor Code I shall. forthwith comply with thosc provisions. <br />WARNINC: Failure to secure workers' compensation coverage is unlawful. and shall subject an anploycr to criminal perr,alties and <br />civil lines up to one hundred thousand dollars ($100,000). in addition to the cost of compcnsation, darnages as providcd for the <br />Section 3076 of the Labor Code, interest and attorney's <br />Dnte: h la /l= <br />( <br />T l)li('1.,\R,\'l'l()N <br />I hereby affirm under penalty of perjury that I arn licensed under provision of Chapter 9 (cornmencing with Section 7000) of l)ivision 3 <br />of the Business and Profcssions Code, and my liccnse is in full force and effect. <br />License - <br />""", {o/h/a <br />W <br />I h*by affm urd6 poalty of pcrjury thd thrc is a condruc{ion hnding agmcy for thc pqfomce of the rcrk for which this pqmil b <br />Civ. C.). <br />Lender's Address: <br />ASPIICANLDECI.AEAIIAN <br />I hrdryatrm und6 poralty ofpcrjury onc ofthc following delarations: <br />Dcmolition Pmit3-Asb6tG Notification Fcdcrsl RcgulatioN (Titlc 40, Part6) <br />-Requircd <br />lrtt6 of l,,lotificarbn <br />-l <br />fsriry thar thc fcdsal rcXulatioro rtgudiag robetos moval re not applicablc to this pDj61. <br />-Z"n r, ,* , *c rcad this spplicstion and statc thst thc sbovc informarion is conqt. I agr to @mply with 8ll City ud Couty <br />ordimcB md Statc law rcldirg to builditrg construclioq ad h*by authorirc rcpreatativG of this City ud Couty to 6ts upor thc <br />above mentioned property for inspection purposes. <br />Applicant or Agent <br />Pernritcc nanle <br />Set Backs D <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bfloor/VenUI ns u latio n <br />Roof Sheathinq <br />Shear Wall <br />Framing <br />lnsulation/Energy <br />Drynruall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif. <br />c.l>loIZ-ZI r(e J ,*Al <br />FINAL 16-l>7,1 [t41t *t243 -UI <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />Contractor:_