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BUILD!NG. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMEI.I+S OWNER BUILDER DELC'ARATION <br />I hrcby affm undq poalty of pojury that I m cxmpt from thc ContractoE' Licw Larv for thc following ltNn (Sc.70-!1.5 ' <br />Busines ud Profesion Code): Any City or County which requiro a pomit to onstruct, ahc. imprcvc. danolish or rcpair uy <br />structe prior to its issumce. also rcquiB thc +plicmt for such pcmit to filc a signcd statmmt tha hc or shc ilticoscd pummt ' <br />to thc provisioE of thc Contractor's Licascd llw (Chsptq 9. Commcncing u'ith Sation 7000 of Division 3 ofthc Busincs and ' <br />Ppfsiom Codc) or that hc or shc is crmpt thcctom ild thc basis for thc allcgcd cxmption. Any violation of Scrion 7031.5 b! uy , <br />applicantforspcrmitsubjCtsthc applicanttoacivilpcnaltyofnotmorcthiltivchundrcddollus($500).,lLr L-1. r omo of thc propcrty. or my cmploye with wagc r thcir rclc compcmation. will do tlrc mrt md thc stnrc1rc is not <br />intqdcd or olfacd for slc (Sc.7044. B6ins 6d Profsiom Codq Thc Cortraclor's Licw taw doe not apply to il ownc of <br />thc properry who buil& or irnprovc ths@tr md N,ho do6 sh w* himsclf or hcclf or thrcugh his or hr om anploye. <br />providcd that such impro@ts rc rct irtqdGd or offqrd for sl.. I[ hos'a6. thc building or impromt b mH rvhhin onc ]an <br />ofcompktion. thc 0*16 Buildc will harc thc hrda ofproviry thd hc or shc did mt tuild or inprorc tic propsiy fur the pupos of <br />slc). <br />_1. u oms of thc prcpsty. m cxclusively contracting wilh licmed contracloE to @nstrucl thc projccl (SG. 7044. Bsins <br />ard Profsbn Codc: Thc Coilraclor's Licmsc Law do6 not apply to m oM6 of propsty who builds or imprcv6 th6on. <br />and who contmcts for such projcts with a ContBcto(s) licds€d pucusrt to thc Contractor's Licw tarv). <br />I am exemot under Section B.P.C. for this reason. <br />Iuat"'U.,l-l C"zLlL <br />I hereby affirm under penalty of perjury one of the follor.r'ing <br />___l have and will maintain a Ccrlificate of Consent to Self-lnsure for workers' compensation. as provided for by Section -i700 of the <br />I-abor Code. for the pcformance of the work for which the perrnit is issued. <br />-l have and will maintain workers' compersation insurance. as requird by Section -1700 of the Labor Code. for the performance of <br />thc work for which this permit is issued. My workers' compensation insurance carrier and policy numkr are: <br />Policy E - ^iroo <br />. <br />fut catity **.in thc psfomncc of rhc work for which thb pcrmit is isucd. I shall not mploy any p6$n in any munc <br />s I to bcomc aubjet to thc wotkm' compctrsation laws of Califomia. ild agrc that if I should beotn. subjst to thc <br />wortm'compqmtionprcvisioroofSelion3T00oflhckborCodelshsll.forthwithcomplywiththorprcvisioro. <br />WARNING: Failurc to sue wrkm'compcmtion ovmgc is unlawful. ud shall subjat e mplo)€r to uimiml pcnahies md <br />civil fine up to one hundrcd thouud dollm ($100.000). in addition to thc cosl of compeetion. damage s providcd for thc <br />Sction 3076 of thc Labor Codq inlo6t ed dtonry's fc. <br />Z <br />I hereby affrrm under penalty of perjury that I am licenscd 9 (commencing with Section 7000) of Division 3 <br />of the Business and Professions Code, and my liccnse is in full fiorce and effect. <br />License Class: License Numbcr: <br />CONSTRUCTION LENDTNG AGENCY <br />I hrcby affrm undo p€nahy of pqjury that th@ is a @mtruction lading agocy for thc pqfomece of thc mrk for which thb pqmh is <br />isucd (Se. 3097. Civ. C.). <br />[rnd6's Nme: <br />- <br />lrndcr's Ad&ess: <br />APPLICANT DECLARATION <br />I herdry affinn undcr penalty of perjury one of the following declarations: <br />Demolition Permits-Asbestos Notification Federal Regulations (Titlc 40. Part6) <br />_Required Later of Notification <br />-l <br />certi& that the federal regulations regarding asbcstos removal arc not applicable to this projecrt. <br />Ecerti$/ that I have read this application and state thar the above information is corrert. I agree to comply <br />ordinances and State l:ws relating to building construction. and hereby authorize representatives of this City <br />above mentioned propeny for inspection purposes. <br />with all City and County <br />and County to enler upon the <br />frpri.rnt or Agent <br />(Permitee name <br />?-o L Lo a <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground \ <br />SLAB Floor <br />S u bfloor/Ve nUI ns u latio n <br />Roof Sheathing <br />Shear Wall -)- <br />Framing / b 12-zl ,&42 u <br />Insulation/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 />Engineer Final Report \ <br />Flood Zone Certif <br /> <br />FINAL l,D-ZZ-q fLc'S/I./S/Zi_S, V/! <br />Certificate of Occu pancy <br />Notes, Remarks, Etc <br />\ <br />_ Contrector:_ <br />)