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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DEIfARATION <br />I hrcby affm undc pcnalty of po'jury that I m qmpt from thc CodractoE' Liccrc t w for thc following l@tr (5€.7031.5 <br />Busiscs afld Prcfsion Code): Atry City or Couty which rcquirc a panuit ao conrtrucl, altq, inprovc' dmolish or rcpair uy <br />strucluc, p(br to its isuucc also rcquic thc applicot for such Fnuit to filc I signcd stdmot thd hc or EIE b licGcd pBusrn <br />to thc prcvisioB of thc Cotrretor's Liccnscd Law (Chapt6 9, Comacing with S€tion 7000 of Division 3 of thc BuinN ed <br />Prcfeiom Codc) or thst hc or shc is qmpt thcfrom md thc basis for thc allcXcd uoption. Ary violation of Setioo 703 I .5 by my <br />applicutforapamitsubjctsthc applicmttoacivilpoaltyofnotmorcthefivchunrlrcddollm($500). <br />-1, <br />u omq of thc prcpcrty, or my cmployG with wag6 6 thcir mlc compquation" wi[ do thc wfik md thc strudG b rct <br />intqdod or oflrcd for salc (5€.7044, Bsins md Profsioc Codc: Thc Cootr&|tr's Liccre law do6 not ryply to e oms of <br />thcpropqty whohrildsorinsrosthso&adwhodo6shwilhimclforhmlforthrcughhisorhoommploye. <br />Fovidcd that such improvqrcnts e not intqdcd or olfqcd for sle, If, howeq, thc building or improvmt is rcld within orc )s <br />ofomptctbq thc O!vo6 Buildr will hrvc thc h[dar ofprcving tha hc or shc did mt hild or improvc thc ptopqty for thc ptrpor of <br />slc). <br />-1, <br />I om6 of the propqty, m qclwivcly cotrttactitrg with licdtscd contractoB to @Ntruct rhc Foj6t (S€. 7(N4, Busins <br />ad Proftsbn Cod€: Thc Contrctor's Licerec Law do6 not apply to d own6 ofpropqty who builds or improvd th6@n, <br />ed who contracls for ruch projcrs wirh a Contracto(s) licqEcd pE@t to thc Cootraclor's Lic@ t w). <br />-l <br />m exmDt udq Setion-. B. & P.C. forthis two. <br />WORI(ER.S' COMPEN SATION <br />DECLARATION <br />I hereby alTinn under penalty of perjury one of the following declarations: <br />_l havc 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 pcrfoffnance of the work for which the pcrmit is issued. <br />-l <br />have and will maintain workers'3700 of the Irbor Code, for thc pcrformance of <br />the work for ls and policy numh are: <br />rD <br />a )OY ?-Z <br />_l certify that in the performance of thc work for which this permit is issued, I shall not employ any person in any manner <br />so as to bccome subject to the workcrs' compensation laws of California and agree that if I should become subject to thc <br />workcrs' compflsation provisions of Section 3700 of the labor Code I shall, forthwith comply with thosc provisions. <br />and <br />the <br />I hercby affirm under penalty of perjury that I am licensed 9 (commencing with Section 7000) of Division -j <br />of the Business and Professions Code. and my license-js in full force and effect. <br />t I <br />7S6lLicenseL.> <br />a C? <br />W <br />t hmby affm undo panalty of pqjury that th@ is I cons(ruction ktrding ag6cy for thc pqfomcc of thc mrl for which this psmit b <br />issucd (Se. 3097, Civ. C.). <br />Lcnder's Namc: <br />Lender's Address: <br />APPLICANT DECLARATTON <br />I her,*y affirm under pcnalty of perjury one of the following declarations: <br />Demolition Pcrmits-Asbestos Notilication Federal Rcgulations (Title 40. Part6) <br />_Required l-rttcr of Notificaion <br />I certifothat the <br />Wr*iry tr,a I have <br />fcderal regulations regarding asbcstos removal a^re not applicablc to this project. <br />read this application the above information <br />ordinances and State l-aws rckting to <br />above mentioned propefly for inspcction <br />Applicant or Agent <br />YAIterlrritcc nanrc x <br />and hereby lhe <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bfloorNenUl nsu Iation /-\ <br />Roof Sheathinq flD6U 5e e ilDre <br />Shear Wall <br />Framing <br />lnsulation/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 Fina! Report <br />Flood Zone Certif <br />,/\\ <br />FINAL O)-/ <br />Gertificate of Occupancy \-- <br />Notes, Remarks, Etc. <br />/ <br />l FY--L <br />A L <br />l-OF LT <br />oF OFS <br />K <br />WARNING: Failure to sccure workers' <br />civil fines up to one hundred thousand <br />Section 3076 of the Code".L intercst <br />a <br />(rb-1-Ll <br />lr\s I O