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BUILDING. INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DETCARATION <br />I h6ety aftm undq pcoalty of pqjury that t m cx€mpt from thc ContrmtoE Licffi Lsw for thc followiag t@n (Se.703t.5 <br />Bwins and Prcfcssion Codc): Any Ciry or County which rcquirG 8 psmit to @narud, alta, improvq dmolish or Epqir uy <br />structrc, pior to its iswcc. also rcquim thc applicut for such pcmit lo filc a sign€d statmot rhd hc or shc is licascd pwant <br />to thc provisioN of thc Cont@tor's Licmscd taw (Chaptq 9. Commcing with Setion 7000 of Division 3 of thc Buim ed <br />PrcfmionsCodc)orthatlEorshcisqmptth@ftommdthebasisfor$ealtcgcdumption. AnyviolationofStrtionT03l.5by|ny <br />applicutforapamitsubjetsthc applimttoacivilpqultyofnotmorcthafivchun&cddollus($500). <br />_1. I om6 of thc praperty. or my mployc with wagc r thcir elc compcnsation, wil do tlrc wqk ard thc {nrtrc b mt <br />intqdcd or offcrcd for sale (Sc.7044, Buins ild ProfesioB Codc: Thc Contraclm's Licw law do6 not eply to u omq of <br />rhc Fopqty who tuil& or impros th@n. ad who dc uch wrt hirelf or hcrclf or thrcugh his or ho om mploye. <br />providcd that such improwt3 rc rct htqd.d or offqcd for slc. lf, hows. the huiklitrg or impromt is sld wthin onc )qr <br />of compbtbn thc Owna Builds will havc the hrrkr of prcvhg that he or $€ did not build or imForc thc propsty for thc prrpoF of <br />sh). <br />-1. <br />I om6 of the propqty, m qcluivcly cortractitrg with licms€d contmcloE to @nstmcl tlE projel (Se. 7044. B6ins <br />ard Proftssim Co&: Thc Contretor's LiccN Law do6 not apply to a own6 of propcrty who builds or imprcv6 lhs@n, <br />md who @ntacls for such prcjd-ts with a Contrac,to(s) lic€nscd puB@t to thc Contractor's Licce kw). <br />_l am exempt B.&reason.\ <br />I hereby affrrm under penalty of perjury one of the following <br />_l havc and will maintain a Certificate of Consent to Self-lnsure for workers' compensation, as providd for by Scction 3700 of thc <br />labor Codc, for thc performance of the work for which thc pcrrnit is issued. <br />_l have and will maintain workers' compensation insurance. as rcquired by Section 3700 of the Labor Code. for the performancc of <br />the work for which this pcrmit is issucd My workers' compensation insurancc carrier and policy numbr are: <br />Policv Number: Exoires: <br />_l certi& 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 becomc subject to the workers' compcnsation laws of California, and agrec that if I should bccome subject to the <br />work6s' compcnsation provisions of Section 3700 of the Labor Codc, I shall, forthwith comply with those provisions. <br />WARNING: Failure to secure workef,s' compersation coverage is unlawful. and shall subject an onployer to criminal poaltics and <br />civil fines up to one hundred thousand dollars ($100,000), in to the cost of damages as providd for the <br />Section Code, interest and attorney's fees. <br />DECI.ARATION <br />I hereby aflirm under pcnalty of perjury that I am liccnsed under provision of Chaptcr 9 (commetrcing with Scction 7000) of Division 3 <br />of the Business and Professions Code, and my license is in full force and effect. <br />License Class: Licerse Number: <br />W <br />I hcby affm udo pqdty of pqjury that thqe is a onstoc{bn landing agocy for thc pqforocc of thc work for which this pqmit b <br />hsucd (Se. 3097, Civ. C.). <br />Lcnder's Name: <br />Lendcr's Address: <br />APPLICANT DECLARATION <br />I h€reby afnrm undcr penalty of perjury one of the following dcclarations: <br />Demolition Permits-Asbestos Notification Fcderal Regulations (Title 40, Parr6) <br />- <br />Required Lrttcr o f Notification <br />_l certi& that thc fedcral regulations regarding asbcstos removal are not applicable to this projcd. <br />_l cerri0 that I have read this application information is correct. I agrec to comply with all City and County <br />ordinances and State Laws relating to <br />above mextioned property for <br />Applicant or Agent <br />I'ermitee nnnle <br />state that thc <br />representatives of this City and County to enter upon the <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bfloor/Ve nUl nsu Iatio n <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Energy <br />Drvwall <br />Ext./lnt. Lath <br />Brown Coat <br />ltllasonry <br />Poo! Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />1 rd 2/ <br />FINAL a \lil <br />'{, <br />PVryt I <br />Certificate of Occu pancy \\V <br />Notes, Remarks, Etc. <br />Contrnctor:. <br />,rr (