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BUILDING. INSPEGTOR RECORD SITE.WORK DATE !D/SIG COMMENTS OWNER BUTLDER DELCARATION I hreby a{Iim unda pcnalty of pojury that I m qmpt from thc CoilractoE' Licre lrw for the following @n (Se.7Dl.5 Buinas ud Profsion Codc): Any City or County which rcquirc a pcmh to @Ntruct, altq. improvg danolish or rcpoir uy structuq Fior to its issmcg aho rcquirc thc eplimt for such pqmit to filc a signcd statmmt rhd hc or slE b licsrscd pmuet ro thc Fovisioru of the Coilractor's Liccnsc{ trw (Chapts 9. Comacing with Sction 7000 of Division 3 of thc Buitw ud Profsioro Codc) or that hc or shc is ampt thrcfrom md thc bosis for thc allcgcd cmption. Any violatiotr of S6rbn 703 I .5 br sny applicmtforapamhsubjetsthe applicettoscivilpcEltyofnotmorcthafivchundrcddollus($500). _1, as owner of the property, or my employees with wages as their sole compensation. witldo the work and the structure is not intended or ofFered for sale (Sec.7044, Business and hofessions Code: The Contractor's License Law does not apply to an owner of the prrrpcrly who builds or improves theron. and who does such work himself or herself or through his or hcr own employees. provided that such ilnprovanents are not intended or ofFerod for sale. If, howwer. the building or improvement is sold within one year of cornplaion, the Orvner Builder will have the hrdcn of proving that he or she did not build or improve the propoty for the purpose of sale). _1, as owner of thc property. arn exclusively contracting with licersed contractors to construct the project (Sec. 7044, Business ard Pmfcssion Code: The Contractor's License law does not apply to an owner of property who builds or improves thereon, and who contracts for such fojects with a Contracto(s) licensed pursuant to the Contrac'tor's Licerse l-aw). -l am exempt under Section-. B. & P.C. for this reason. WORKERS' COIVIPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: -l have and will maintain a Certificate of Conseirt to Self-lnsure for workâ‚¬rs' compensation, as provided for by Section 3700 of the l-abor Code, for the performance of the work for which the pennit is issued. ' I have and will maintain workers' compcnsation insurance. asi required by Section 3700 of the Labor Code, for the pcrformancc of the work for which this pâ‚¬ilnit is issuod My workers' compqudion iruurance carrier ard policy numbcr are: c (o- Policy oq '/zo >Z AI certifu that in the performance of the work for which this permit is issucd, I shall not cmploy any person in any manner so as to become subject to the workâ‚¬rs'compemsation laws of California, and agree that if I should becorne subject to the workcrs' compensation provisions of Section 3700 of the Labor Code, I shall. forthwith comply with those provisions. WARNING: Failure to secure workers' comperuation coverage is unlawful, and shall subject an onployer to cdminal pcnalties and civil fines up to one hundred thousand dollars ($100,000), in addition to the cost of compensation, damages as provided for the Section 3076 of the tabor Code, interest and attorney's fees. ,,,". t7/tc(/? nZ I aovn...^. kek ChA IherebyafIirmunderpcrraltyofpcrjurythatIamlicerrscrt,ffiChapter9(commencingwithSection7o00)ofDivision3 of the Business and Professions Code, ard my liccnsc is in full force and effect. License ,r*, B/ d0/c 4 6/cs7 LicenseNumber: \ r L1 6e/ c/ ,,,", lv l4t/u2 I (rcr.Gr-,tH?/L W t hocby alfm undo poalty of p6juy thal thsc is 8 @nstrucrbr kndiry agacy for thc psfomacc of thc work for which this [mil b isucd (Se. 3097. Civ. C.). l*ndq's Nmc: I-cnder's Ad&ess: AIII.ICANLDECI.ASAIIA! I hothy aftru unds pcnalty of pajury orc of thc following dclanriore: Dcmolition Pmits-Asb6tos NotiIicstiotr Fcd@l Rc?ulatioB (Titlc 40, P{t6) lRcquircd latq of Notificalion -l cdiry thrt thc fcdeml rcgulntioro rcgarding sbctos moval uc not applicablc to this prcjct. z_l cctiry thot I havc ud this application and 3tatc that thâ‚¬ abovc infomrliotr is o161. I agc to @mply with all City ad Couty odimc ,rd Statc LM rEhiDg to building @nsnrcriou ad hacby uttoriz rctrMtdiv6 of thb city ed Coutrty to atq upotr thc abovc mtioncd prcpory for inspoctior pupos Applicant or Agent Permitee name o,t",t0/&/2o7) Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloo r/Ve nUI n s u I atio n Roof Sheathing Shear Wall Framing lnsulation/Enerqy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif I lolnle,,JAb I V f. FINAL lol nla lln Gertificate of Occu Notes, Remarks, Etc.