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BUILDING- !NSPECTOR RECORD SITE.WORK DATE ID/SIG COMMENTS Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloor/VenUI ns u lation /+\ Roof Sheathinq /D-11 -Ll Lr) frq) Shear Wall \rz Framinq Insulation/Energy Drynruall Ext./lnt. Lath Brown Coat [\4asonry Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Final Report I Flood Zone Certif .a), FINAL D-n-LL wX77/., Certificate of Occupancy \-.- Notes, Remarks, Etc.I -v dP KI /}ODD I Dt,|VV / I hoeby aflirrn undo penahy of pcrjury that I m exqnpt from thc ContrsctoE' Licosc Law for the following rcen (Se.7031.5 Ilusino md Profcion Code): Any City or County which requirs a pomit to coNtruct. alte, improvq dcmolish or repair ay struc:lwe. prior to its isuilcc. also rcquic lhc applicilt for such pemit to filc a signed slalmot that hc or shc b licscd pmmt to the prcvEions of the Contretor's Licmrcd taw (Chapt6 9. Commencing with Setion 7000 of Division 3 of the Busins ud Prefesions Code) or that he or shc is exmpt thftftom od the basis for thc allcged exmption. Any violation of Sstion 7031.5 by any subjects thc applicant cir,il penalty of not than five hundrcd dollars ($s00). as with wages as their sole compensation. and Professions Code: The Contractor's u'iII do the s'ork and the structure is not intcnded Liccnse Law does not apply to owner of the property who builds or irnproves thereon. and who does such work himself or herself or through his or her own employecs, provided that such improvemcnts are not intended or offered for sale. I[, howet/er. the building or improverncnt is sold within onc year of conrplaion, the Orvner Builder will have the hrden of proving that he or she did not build or irnprove the prope'ty for the purposc of sale). -1. as owner of the property, arn exclusively contracting with licensed contractors to construct the project (Sec. 7U4, Business and Profession Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon. and rvho contracts for such projects with a Contractor(s) liccnsed pursuant to the Contractor's License l-aw). I am exemot under Section DECLARATION I hereby affrm under penalty of po'jury one of thc following declarations: _l have and will maintain a Certificate of Consent to Self-lnsure for workers' cornpensation, as provided for by Section -j700 of the Labor Code. for the perfonnance of the work for which the permit is issued. -l have and will maintain workers' compensation insurance. as required by Section 3700 of the Labor Code. for the pcrformance of thc rvork for which this pennit is issued. My workers' compensation insurance carier and policy number are: cerrifu that in the performance of the work for which this perrnit is issued. I shall not ernploy any person in any manner if I should becorne subject to thesoas to become subject to the workers'compensation laws of California. and agre'e that workers' compensation provisions of Section 3700 of the l-abor Code. I shall. forthrvilh comply with thosc provisions. WARNTNG: Failure to sec'ure n'orkers'compensation coverage dollars ($100.000). in r and civil fines up to one hundred thousand for the Section 3076 of the interest I and attorney's fees.2 DECI.ARATION I hcrcby affirm undcr penalty of perjury that I arn licensed under provision of Chapter 9 (comrnencing with Section 7000) of the Business and Professions Code. and rny license is in full force and effect. License Class: License Nurnber: Contractor: W I hrcby affrm undo penalty of pcrjury that thqe is a construction loding agacy for thc prfomuce of thc work for which this psmit i3 issucd (Ss. 3097, Civ. C.). lddd's Nmc: Lender's Addrcss: APPLICANT DECLA]IATION I hercb}, amrm under penalty of pcrjury one of the following declarations: Demolition Permits-Asbestos Notification Federal Regulations (Title 40, Part6) _Required Lctt er of Notification above rnentioned property for inspection Applicant or Agent I'ernrilcc nanle this project. the !-- L Io a It,lt fr- Carrier:-