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BUILDING. INSPECTOR REGORD <br />SITE.WORK DATE !D/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hacby affm unda panalty of pcrjury thar I m qcmpt fiom thc ContracloE' Lirc kw for thc following !!en (56.7031.5 <br />Buincs aad Prcfesion Codc): Any City or County which rcquic a pqrnit to @nstruct, altq. improvq danolish or rcpair my <br />structE, prior to its issumcc, also rcquirc thc applicet for such pcnnit to 6lc 8 signcd stalmt thal hc or slE b licmcd pu$snt <br />to thc provi3ioB of thc Contrrctor's Liccnscd law (Chaptq 9. Comflcitrg with S€1ioo 7000 of Division 3 of thc Buins md <br />Prcfsio$Codc)orthathcorshcisacmptth@fromedthcbosisforthcallcgcdqmption. AryviolationofS4lbnT03l.5bymy <br />spplicmt for I padt subjcts thc applimt to a civil pcmlty of not morc thm fivc hundrcd dollas ($500). <br />_1, 6 oM6 of ahc pope'ry. or my mployG with wEg6 6 th€ir $lc comparstion, will & dE wo* ad tlE strudrc b rct <br />intqrded or offcrcd for slc (Sc.7044, Buine od Prcfeioro Codc: Thc Coilractor's Li@ I:w doc not rydy to m omq of <br />thc Fopqty who tuilds or impovc thmn, ad who doc sh wrt hiruclf or hqslf or thrcugh his or ha om mploycc. <br />prcvidcd thar such improvqrcils e rct intqdcd or oflacd for sh. lf, how, ttE hrilding or improvaErt b sH within onc )a <br />of complnioi\ thc Ownq Buil& wilt havc thc h[do of provilrg thrr hc or slrc did mt build or irryrow thc propary for thc p[pos of <br />slc). <br />_1, a ow6 of thc propcty, m ucluivcly ontracting with licqEcd cortEtoB to constnrct thc Foir{ (Sc. 7(X4, B6i!B <br />ard Proftsim Code: Thc Contrctor's Liccre Law doc not apply to il ownq of propqty who builds or improvG thqor\ <br />md who contncts for such ptoj6t with I Contracto(s) licqEcd puBulnt to thc Conre{or's Lic@ [5w). <br />_l am exempt under B. & P.C. for this reason. <br />Owner: <br />WORIGRS' COMPENSATTON <br />DECLARATTON <br />I hereby affrrm under penalty of pcrjury one of the following dcclarations: <br />_l have and will maintain a Certifrcate of Conscnt to Sclf-lnsure for workers' compssation, as provided for by Section 3700 of the <br />Labor Code. for the pcrformancc of thc work for which the pcrrnit is issued. <br />_l havc and will maintain workers' compensation insurancc, as requircd by Scction 3700 of the Labor Code, for the performance of <br />the work for is issued.compcnsation insurancc carrier and policy number are: <br />\1) <br />poricy N" *, .- O ?s 07 W1, - 1-'O Expires:I <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 as to become subjcct to the workers'compensation laws of California, and agree that if I should become subjcct to the <br />work€rs' compensation provisions of Section 3700 of the Labor Code, I shall. forthwith comply with those provisions. <br />WARNTNG: Failure to sccure workers' compcnsation coverage is unlawful, and shall subject an ernployer to oiminal penalties and <br />compensation, damages as provided for thecivil fines up to one hundred thouszurd dollars in addition to the cost of <br />Section 3076 interest <br />t <br />C-*r <br />DECI"ARATION <br />I hereby affrm under pcnalty of perjury that I arn licensed under provision of Chapter 9 (commencing with Section 7000) of Division 3 <br />of the Business and Professions Code, and my license is in full force and cffect. <br />I &Cr\ b9\License <br />u <br />W <br />I h@by 8lrm undq pcnalty of pcrjury that thqc is I @nsruclion kodirg ag@y for thc pqfomcc of thc rcrt for which thb p6nit k <br />issucd (Se. 3097, Civ. C.). <br />Lendcr's Name: <br />Lender's Addrcss: <br />APPLICANT DECLARATION <br />I heney afErrn undcr pcnalty of perjury one of thc following dclarations: <br />Demolition Pcrmits-Asbcstos Notifrcation Federal Regulations (Title 40, Part6) <br />-Required <br />lrttcr o f Notification <br />-l <br />certi$ that the lederal regulations regarding asbcstos removalare not applicablc to this project. <br />-l <br />certi$ that I have read this application and staG that the above information is correct. I agree to comply with <br />ordinances and State Laws rclating to building construction, and hereby authorizc repres€ntatives <br />above mcntioned property for <br />Applicant or Agent <br />Perlrritce nanlc <br />1*. <br />n <br />all City and County <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bfloor/Ve nUI n s u latio n <br />Roof Sheathing <br />Shear Wall <br />Framing <br />Insu lation/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 />F!NAL /a/qa LC /9*uta5 vj <br />Certificate of Occupancy <br />Notes, Remarks, Etc.