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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/S!G COMMENTS OWNER BUILDER DELCARATION <br />I heeby atfm unda pcnalty ofpcrjury thar I m cxcmpt from thc Cootractom' Liccre llw for thc following rcisli(Se.?031.5 <br />Busincs ud Prof*ion Codc): Any City or County which rcquirc a pomil to @nstruct, alto, improvc, <bnolish or rrnair4nl <br />structurq prior to its isuuce, also rcqute the eplicat for such pcrmit to filc a signcd stdmmt thal hc or slrc b licwcd pwant <br />to thc prcvisioc of the Contractor's Liccnscd law (Chapts 9, Commmcing with S*tion 700O of Division 3 of thc Buinw md <br />Prcfesioro Codc) or that hc or shc is cxcmpt thqefrom ed the basis for thc allcgcd cxoption, Any violation of Sction ?031.5 by'my <br />applicantforapemitsubjetsthe applicanttoscivilpcnsltyofnotmorethilfivehundrcddollus($500). <br />_1. re omq of thc !rcperty, or my cmplolc with waga re thcL $le compensation. will do thc w* ad [E strwlrc b rct t <br />intoded or offscd for slc (Sc.7044, Buine md Profeioro Codq Thc Contractor's Licce trw do6 not eply to a om6 of r <br />thc propqty who builds or improvc tlE@n, dd who do6 such wr* himsclf or hwlf or lhrcugh his or ho om mplo1rc, <br />providcd that such impromts rc mt intodcd or oflbrcd for slc. lf. howq. the building or imp.otqnd is oH within onc )qr <br />of compktion, the Oma Buiklc will have thc hrdo of prcving thd hc or $c did mt tuild or improvc thc plopdy for tlE purpos of <br />$le). <br />_1, 6 ownq of the prcpsty, on cxclsivcly contracting with lictrcd conaractoB to coretruct thc Fojccl (SE. 7044, Buine <br />md Profusion Code: Thc Contretor's Liccnsc Law do6 not apply to u own6 of property who builds or imprcvca thq@n, <br />and who contmcts for Euch proj@ts with a ContBcto(s) licsql pus@t to the Contractor's Lic€e Law). <br />-l <br />am exempt under Section-, B. & P.C. for this reason. <br />WORKER,S' COMPEN SATION <br />DECLARATTON <br />I hereby affirm under penalty of pojury one of the following dcclarations: <br />-l <br />have and will maintain a Certificate of Consent to Self-lnsure for workers' compensation. as provided for by Section 3700 of the <br />Labor Code, for the perfonnance of the work for which the pennit is issued. <br />/l*t and will maintain workers' compensation Section 3700 of thc Labor Code, for the pcrformancc of <br />rvhich pennit issucd.carrier and policy number are: <br />Policy \ <br />-l <br />certify that in the pqforuncc of the work for which this permit is isucd, I shall not mploy any p6on io any mmno <br />rc m to bccome subjct to thc work6' comp6ation laws of Califomia. ud agre that if I should bccom€ subjet to the <br />work6' compostionprcvisioro of Setion 3700 of the tzbor Codc I shall. forthwith comply with thor provisiom. <br />WARNING: Failurc to suc work6'comp€ffition covmge is unlawful. ud shall subjat e mplolq to qimiml pcrEhks ild <br />civil fins up to onc hudrcd thoMd dollG ($100,000), in sddition to thc cost of ompcnsation, damagd 6 providcd for the <br />Scction -j076 of the labor Code. interest and attorney's <br />I hcreby aflinn under penalty of perjury that I arn licensed 9 (cornrnencing rvith Section 7000) of Division 3 <br />of the Business and Professions Code, and rny license is in full force and effect. <br />License Nurnber: <br />uq I <br />W <br />I hwby affrm undo penalty of psjury that th6c is I mNtruclion loding agmcy for the perfomcc of the wrk for which this pqmit b <br />issued (Se. 3097, Civ. C.). <br />Lender's Name: <br />I-cnder's Address: <br />APPLICANT DECLARATION <br />I herdry allirm under penalty of pcrjury one of the following declarations: <br />Dernolition Perrnits-Asbestos Notification Federal Regulations (Title 40. Pil16) <br />-Required <br />Letter of Notifrcation <br />_l ccrti$ that the fbderal regulations regarding asb€stos removalare not applicable to this project. <br />Mr*rfythat I have read this application and state that the with all City and County <br />and County to ext€r upon theordinances and State [-aws relating to building construction. <br />above rncntioned property for inspection <br />IApplicartl or Agcnt <br />Itcrnrilce nAnle <br />I <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bfloor/VenUl ns u !atio n <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Energy <br />Dryruall <br />Ext./lnt. Lath <br />Brown Coat <br />[/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />FINAL <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />14 <br />1 <br />f