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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.coMMErvrs O1VNER BUILDER DELCARATION <br />I hocby aflim unda pqnlty of pcrjury that I m cxcmpt ftom thc Contraclon' Licw law for thc followillg rcmn (Ss.7031.5. <br />Buines ard Profsion Codc): Any City or County which rcquirc a po'mit to omtruct. ahq, imprcvc, dmolish or rpair ay <br />sruoue, prbr to its issuace. also rcquirs thc applicst for such pcf,nit to filc s signcd statmmt thar hc or slp b licmed pwart <br />to thc provisiom of thc Contretor's Liccnscd Law (Chapts 9, Commcing with Sction 7000 of Division 3 of thc Bwins aild <br />PrcfosionsCodc)orthatheorshcisdmptthscfromadthcbesisforthcallcgcdcxmption. AnyviolationofselionT03l.5bymy <br />applicmtforapemitsubjersthc applicmttoacivilpcmltyofnotmorcthelivchundrcddollus($500). <br />-1, <br />o omq of thc propcrty, or my mployc with wag6 I thcir mlc compcrsaion. will do thc wqk ad thc ltrudr b mt r , <br />intqrdcd or offopd for slc (Se.7044, Buins md Prpfsioro Codc: Thc Conttactor's Licffi [rw do6 not eply to s omq of <br />thc Fopqty who hril& or improvs tlEo[ ed who do6 such w]* himsclf or hmclf or thrcugh his or ha om mploye. <br />prcvidcd that such imprcvffits rc rct intqrdcd or offsrd for sb. If. hoPBq, thc buildirg or imFovqn@t is rcld within one )an <br />ofcomplction, thc o\rno Buildq wil harc tlE hrdE ofproving thd lE or $c dil mt hrild or improvc thc popoty br thc prpos of <br />slc). <br />_1, I omq of thc propcty, m uclusivcly contrscting with lic@€d contractoB to @Ntruct thc prcjcl (Ss. 7044, Buine <br />and PDfusbn Code: Thc Cotrt6tor's Liccnsc Law doc not apply to a own6 of propcrty who builds or imprcvc thqorl <br />ud who contrads for such projGls with a ContEclo(s) licos€d pmwt to thc Contraclor's Licw kw). <br />-l <br />am exempt under Scction-. B. & P.C. for this reason. <br />WO RKER"S' COM PENSATIO N <br />DECLARATION <br />I hereby affrrm under penalty of perjury one of the following declarations: <br />_l 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 perforrnance of the work for which the pennit is issued. <br />_l have and will maintain workers'3700 of the Labor Code, for the performance of <br />the work for u*hich this ocnnit <br />/r,/.sh'e <br />is and policy number are: <br />Poricy Numbe,: FfZ bl LL '1nq Expires: <br />_l certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner <br />so as to become subje,ct to the work€rs'compcnsation laws of California, and agrec that if I should become subject to the <br />workers' compensation provisions of Seclion 3700 of the Labor Code. I shall. forthwith comply with those provisions. <br />WARNING: Failure to secure workers' compensation coveragc is unlawful, and shall subject an onployer to criminal pcnalties and <br />civil fines up to one hundred thousand dollars ($100,000). in addition to the cost of compensation. damages as provided for the <br />Section 3076 of the labor Code, interest and attorncy's fees. <br />Applicant: <br />LTCW <br />DECI.ARATION <br />I hereby affrm under penalty of perjury that I am licenscd under provision of Chapter 9 (comrnencing with Section 7000) of Division 3 <br />of the Business and Professions Code, and my license is in full force and effect. <br />License t oz1 cLFl <br />W <br />I hmby affm undo pqBtty of pdury that thqr is a @Etruciioo lcding ag6cy for th. pqfolmcc of thc m* for which this pomil b <br />Civ. C.). <br />Lender's Address: <br />APPLTCANT DECLAITATION <br />I hereby allinn under penalty of perjury one of thc following declarations: <br />Demolition Pennits-Asbestos Notification Federal Regulations (Title 40. Par16) <br />-Required <br />lrtter of Notification <br />_l certi& that the federal regulations regarding asbestos removal are not applicable to this project. <br />J ..rri5, that I have read this application with all City and County <br />ordinances and State Laws relating to and County to enter upon the <br />above mentioned property for <br />Applicant or Agent <br />Permitee name G* <br />u <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bfloo r/Ve nul n su latio n <br />Roof Sheathing <br />Shear Wall <br />Framing <br />lnsu lation/Energy <br />Drnrvall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonrv <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif. <br />\ <br />FINAL rdan-lr,^r \xw <br />Certificate of <br />Notes Remarks Etc <br />I