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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG COMMENTS OWNER BUILDER DT:LCARATION <br />I hoeby aflim undc panalty of perjury that I m acmpt ftom thc ContractoB' Licce Law for thc followiog lwn (56.7031.5' <br />Bwin6s ild Profeion Codc): Any City or County which rcquiu a po:nit to coNtruct, alts, imprcvq donolish or repair uy <br />structue, prior to ils issumce, also rcquira thc applicmt for such pcrmit Io filc a signcd statmat lhal he or slrc is licdEcd pGmt <br />to Ihe povisioB of the Contractor's Licemcd law (Chaptq 9, Commmcing wilh Scction 7000 of Division 3 of the Buins ud <br />Pofwions Code) or that hc or shc is qcmpt thscFotn od thc bssis for thc allcgod cxop(ion. Ary violation of Sclion 7031.5 by uy <br />applicantforapamitsubjctsthe applicuttoacivilpcnaltyofnotmorcthafivchundrcddollm($500). a <br />-1, <br />r omo of thc propcrty, or my mplo)6 with wag6 I thcir $lc comp@sation. will do thc work ad the stndrc b not <br />intqrded or offsed for slc (Se.7M4. Buine md Profeioro Codq Thc Contractor's Liccr t w do6 not apply to m oms of <br />thc pIopqiy who builds or imprcG thcotr ad who do6 such mr* himsclf or hc$lf or thrcugh his or ho om @ploy6, a <br />providcd that such improvqrcnts rc rct intodrd or ofTqcd for slc. lf, how. thc hilding or improvcmt is mld within onc )an <br />ofcompldon, thc Orvno Buiktq will havc thc hrda ofpoving rha he or dre did rct tuild or irnFovc ihc propsry for the puposc of <br />sdc). <br />_1. c omq of thc Fopqty. m cxclBively contracting with licGcd contractoB to coGlruc{ thc projcl (S€. 7044, Bwin6 <br />od Profssbn Code: The Contrclor's Licensc Law do6 trot apply lo m owtrs of propeny who builds or improvG th6@n, <br />md who contncts for such p{oj€ts with a ContEcro(s) licGcd puEuant to thc Conlractor's Licre [rw). <br />-IalncxemptunderSection-.B.&P.C.forthisreason. <br />lloto' <br />WORKERS' COMPENSATION <br />DECLARATION <br />I hercby affirm under penalty of perjury one of the following declarations: <br />_l have and will maintain a Certificate of Consent to Self-lnsure for workers'cornpensation, as provided for by Section 3700 of the <br />Labor Code, for the p€rfonnance of the work for which the pennit is issued. <br />_l have and will maintain worksrs' compensation insurance, as required by Section <br />the work for which this pennit is issued. My workersiompensation insurance carier <br />ca;ier. ' 9fa?e <br />-3700 of thc Labor Code, for the performance of <br />and pplicy nunrber are: <br />t /r /zz-Policy <br />-l <br />cerrify that in the perfcrrrnance of the work for which this perrnit is issued. I shall not <br />so as to become subject to the workers' compensation laws of California. and agre€ that if I <br />employ any person in any manner <br />should become subject to thc <br />and <br />the <br />Section 3076 of the Labor Code, interest and <br />l)t,.('t.,\ tt. \'l'l( )N <br />I hereby affirm under penalty of pcrjury that I am licensed under provision of Chapter 9 (cornmencing 7000) of Division 3 <br />of the Business and Professions Code, and my licensc is in full force and effect./,ot4z?-lLiccnscNumber: <br />""", z lo/tr/zl Ior'rvt <br />CONSTRUCTION LENDING AGENCY <br />I h@by affm und6 penalty of psjury that th@ is 8 consruclion lading agocy for the pqfomcc of thc work for which this pqmit b <br />issucd (Sa. 3097. Civ. C.). <br />Lcnder's Name: <br />Lcnder's Address: <br />APPLICANT DECLARATION <br />I hqtbyaftinn under penalty of perjury one of the following declarations: <br />Demolition Permits-Asbestos Notification Federal Regulations (Title 40, Pan6) <br />_Required Letter of Notification <br />( certi& that the federalregulations regarding asbestos rernovalare not applicable to this project. <br />_l cerri8 that I have read this application and state that is corrcct. I agree to with all City and County <br />and County to enter upon theordinances and State Laws relating to building construction,of this <br />abovc mentioned property for <br />Applicant or Agent <br />I'errrrilcc nirnrc <br />o,,", CO ig { tl <br />I <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bfloor/VenUl ns u lation I I <br />Roof Sheathinq la/te/zr <br />Shear Wall tt tv <br />Framing I <br />lnsulation/Energy <br />Drnruall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputv Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />FINAL tJn/*t <br />Certificate of Occupancy ,l \-/ <br />Notes, Remarks, Etc. <br />Owner: <br />provisions. <br />dollzu's in addition to thc cost