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BUILDING- INSPECTOR RECORD SITE-WORK DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION I hcrcby uffirm undcr pcnahy of perjury that I u cxcmpt frcm lhc Contracto6' Liccnsc hw for thc following rcasn (Str.7031.5 Business and Prcfcssion Codc): Any City or County which rcquircs a Jrcrmit to @nslruct, alts. improvc, dcmlish or rcpair uy strucluc. prior lo its issuancc, also rcquircs thc applicant for such Frmit to file a sigrcd stltcmnt that hc or shc is liccnrcd puruant to thc provisions of thc Contractor's Liccnsd law (Chaptcr 9. Commrcing with S$Iion 7000 of Division 3 of thc Busincss and PrcfcssionsC<rdc)orthBthcorshciscxcmplthcrcfromandthebasisforthcallcgcdcxcmpaion. AnyviolationofsNtion?03l.5byany {pplicanl lbr I pcrmit subjats thc spplicont to a civil pcnalty of lot morc than fivc hundrcd dolles ($500). -1. as owncr of thc propcrty, or my cmployces with wagcs as their solc comJrcnsalion. willdo the work and thc strLrcturc is not intcndcd or ofl'cred for salc (Scc.7044. Business and hofcssions Codc: Thc Contractor's Liccnse [,aw docs not apply to an owner of thc propcrty who builds or inlprovcs thercon, and who drrcs such work himsclf or hcrsclf or through his or hcr own cmployccs, providcd that such intprovcnrcnts arc not intcndcd or offercd for sah. lf. howcvct thc building or improvcrncnt is sold within onc year of cornplction. lhc Owner Buildcr will have thc burden of proving that hc or shc did not build or improvc thc propcrty for thc purpose of sale). -1. as owncr of the propcrty, am exclusivcly contracting with licenscd contractors lo construct thc projcct (Scc. 7W, Business and Protcssion Code: Thc Contractor's Liccnsc Law docs not apply to an owncr of propcrty who builds or improvcs thcrcon. and wh<l contracts for such projects with a Contractor(s) licensed pursuant to the Contractor's Liccnsc Lrw). -IamcxcmptunderScction-'B'&P.C.forthisrcason.Owner:_ WO RK II ILS' COM PTNSA TION DECLARATION I hcreby al'firnr under pcnalty of pcrjury onc of lhe following dcclarations: -lhavcardwillmintainaCertificatcofconsnttoSclf-lnsurcforworkqs'compcnsation.as lrevidcdforbySetion3T00ofthc labor (lxlc, for thc pcrfonmncc ofthc work for which lhc pcrmit is issucd, NEnu"c una *itt mintain workers' compcnsstion insunncc, as rcquircd by Sction 37OO of thc Latnr Codc. for thc pcrformnce of lhe work for which is issued. My workcrs' compcnsation insurancc carricr and plicy numbcr are: L-r Policy sSzz tC>.l'zl tS cenify rhar in thc pcrformrcc of thc work for which this [rcrmit is issucd, I shall nol cmploy any [rcmn in rny m.nrcr m os to bccorrc subFcl lo thc workes'mmlEnsation laws of Californio. ond agre that if I should bccom subjcct to lhc worktrs'@nrpcnsalionprovisionsofscction3T00ofthctaborCodc,lshsll,forthwithcomplywiththospmvisions. WARNING: Failurc to surc workcrs' compensation mvcmge is unlawful. and shall subjcct an cmploycr to Giminal lEmltbs and civil fincs up to orc huMrcd thousand dollils (S1m.000), in addilion to thc cost of comlrcnsation, dmges as providcd for thc Section 3076 of the [:bor Codc, intcrest and attorrrcy's fecs. ,",",(Ol2\ lz\i I I hcrcby allrm under pnalty of perjury that I am liccnscd undcr provision of Chapter 9 (cornmcncing with Scction 7000) of Division 3 of thc Busincss and Profbssions Codc, and my liccnsc is in full forcc and cffect. Cto Qr31 SGLiccrtscNunrbcr: L\z v\vrConlractor: CONSTRUCTION LENDING AGENCY I hercby allirnr undcr;rnally of lErjury lhal thcrc is a conslruction lcnding agcrcy for thc Jrrfomne of thc work for which this Frmit is issucd (S@. 3097. Civ. C.). lrnder's Addrcss: APPLICANT DECLARATION I hcreby aftinn undcr penalty of pcrjury onc of the fbllowing dcclarations: Dcmolition Pcrmits-Asbcstos Notification Fcdcral Regulations (Title 40. Ptrt6) _Rcqu ircd lrtter of Notilication -l ccdify Ihat thc fcdcralrcguldtions rcgarding Nbcstos rcmovalec not applicablc Io Ihis prcjcTt. Mc".tlfy rlur I havc rcad this spplicotion and statc that thc atnvc inforrolion is comcl. I agre to @nrply wilh all Cityand Counly ordinarccs ild Slalc ljws rclatinS to building construction, atxl hcrcby oulhoria rcprcsntsliws of Ihis City snd County to cntcr upon thc above rrrcntioncd propcrty lbr Applicant or Agent Permitee n$nle n..a^.\.? I Ltlzl Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bf loor/Venvl ns u latio n Roof Sheathinq Shear Wall Framing lnsulatio nlEnerqy Drywall Ext./lnt. Lath Brown Coat [\Iasonry Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif fl \/a .nt At // r///1/ 6tt A"w)n FINAL ,/r u Fz1 //4 /{--4.- / ,//vc r-/ d,l Certificate of Occu Notes, Remarks, Etc. Date:_ Carrier:- Applicant:_ [rnder's Nanrc: