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INSPECTOR RECORD SITE-WORK DATE ID/SIG COMMENTS OWNI'R iUILIIER DELCANATION I h@by aflim und6 podty of pcrjury that I am ermpt fom thc Contradm' Li6sc Law fc thc followin8 l6on (5(,7031.5 Bcin6s and Pmf6sion Codc): Any City or County which.cquiG a pcrrrit to @Ntrucl. alld. imprcvc. dcmlish or rcpair any sructurc. prior lo ila isil8re. also rcquiG thc applicant for such pcmit to fi|. a signcd st.tffit thst hc or shc is licmcd puBuant to lhc prcvisioN of tha Contractor's l,imscd taw (Chaptq 9. Cmmocing with Setion ?000 of Divisim 3 of thc Busin6s and Prefsio6 Codc) n that hc G shc is crmpt th@frun and rhc b6is for thc alleg(d cxmption. Any violatim of Sdion 701 I .5 by any appliqnt fq r pcnnit subjcls thc epplicant to I civil pcnalty ofnot morc than fivc hundrcd dollas (t500). [], o owno of thc prepffy. or my mployG with wag6 6 rhcir sole ompcnsation, will do th. wdl and thc stufrrc is nd inhd.d o offqrd for slc (5@.7044. Busin6s ild Prcfcsioc Code: The Conmctor's LiMsc Law dG not apply to an wna of thc prcpcrty who buil& m irnpwc thqmn. and who &6 such wqt himsclfor h6clf or threu8h his or h6 own mpkrycs. prcvid.d lhal such imprwoots e no( intodcd 6 offqrd fotr slc. If. hNea. thc building tr improvmt is sld within w yar of mplaio. drc Own6 Buildcr will havc thc burda ofFovirg lhar hc 6 shc did nol build a impmc frc pmpenv f6 tE ErpGC ofslc). NO I. a* owner of the property. am exclusively contracting rvirh licensed contractors to construcl the project (Sec. 7044. Business and Pr,ofession Code: The Contraclor's l,icense Larv does not apply to an owner of property who builds or improves thereon. and who contracts for such projects with a Contracto(s) licensei pursuant to the Contractor's License Law). No I am exempt under Section . B. & P.C. for this reason. WORKT'RS' COMPT'NSA,TION DFCI ARATION I hereby afTirm under penalty of perjury one of the following declarations: !l n.r" anct will maintain a Certificare of Consent to Self-lnsure for workers' compensation. as provided for by Section 3700 of rhe Labor Code. fcrr the performance of the work for which the pennit is issued. YES _l have and will maintain workers' compâ‚¬nsation insurance. as required by Section -1700 of the Labor Code. for the performance of the work for which this pcrmil is issued. My workers' compcnsation insurance carrier and policy number are: . Sccurfi Natlonal L alTter: 8WC1373E0 Policy Number:_ NO Expires: 1112312021 _l cerrifo that in the performance of the work for which this p,ermit is issued. I shall not employ any person in any manner so as to become sub.iect to the workers'compearsation lau's of California. and agree that if I should become subject to the workers' compcnsation provisions of Section .1700 of the Labor Code. I shall. forthrvith comply u'ith those provisions.. WARNING: Failure to secure rvod<ers' fines up to one hundred thousand dollars compensation coverage is unlawful. and shall subiect an employer to criminal penalties and civil ($100.000). in addition to the cost of compensation, damages as provided forthe Section 3076 of the l.abor Code. interest and attomey's fees. LICTNSFN ('ONT]LdCTOR DTCI AR,ATION I hereby a(firm under penalty of per.iury that I am licensed under provision of Chapter 9 (commencing with Section 7000) of Division .1 of the Business and Professions Code. and my license is in full force and effect. c2GC3G License Class:_ 7t'1405 l.icense Number CoNSTRUCTION I FNntNG ^GTNCYI hereby afTirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. .1097. Civ. C.). l-ender's Name: Lender's Address: APPT I('ANT NFCI AITATION I herelry affimr under penalty of perjury one of the followrng declarations. Denrolitron Pernrits-Asbestos Notrficatron Federal Regulahons (Title 40. Part6) !a Required trtterof Notification YEs I câ‚¬rtiry that the federal regulations regarding asbesros rcmoval are not applicable lo this project. ! I ccrti$ that I have @d this application dd st.tc that rhc atnvc infomation is cor6t. I agc to comply with .ll Cily ad Couty ordinarcG and Stdc llws r.lating to building coNtruction, ild hocby authori4 rcprcscnlaliv6 ofthis City and County to cnla upon thc abovc hcntioncd prepcdy for inspcction purpos6. Reroof Roof (Diaphragm Sheathing/Frame) Structural Final Plumbing Under Floor I Under Slab Rough Shower Pan / Tub Test Water Service Sewer / Sewer Cap Gas Air Pressure Test Plumbing Final Electrical Service (Meter / Panel) Grounding / Bonding Rough Electrical Final Mechanical Gas Air Pressure Test Rough Piping (HW, CW, etc.) Exhaust Ducts t \.-. Mechanical Final toln-rl,ra !,Nr,ot\\ t Notes, Remarks, Etc.