101101321 - Permit - Laserfiche WebLink

Home Browse Search

BUILDING. INSPECTOR REGORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hftLy aUirm undo penalty of pajury that I m cxmpt from thc CoilracloB' Licce Law for thc following lwn (54.7031.5 Busin6s ud Profsion Codc): Any City or County which rcquira a pannit to co$iruct. altq, imprcvq &molish or npair uy struc1[c, prior to ils isumcq also rcquirB thc applicet for such pcmit to filc 8 signcd stalmot thar he or shc is licqtscd pmuut to thc prcvisioB of thc Contnctor's Liccnscd Law (Chsptq 9, Comcncing with Setion 7000 of Division 3 of thc Bwins ud Prcfe$ionsCodc)orthatheorshcisqmptthecfromadthcbssisforthcallcgcdcxoFion. AtryviolationofSctbnT03l.5bymy applicat fur a pcrmit subjats the applicut to a civil pcElty of noi more thu fivc hundrcd dollas ($500). _-1, 6 ownfi of thc prcpcny, or my mploye with wags r thcir $lc compâ‚¬Eation. will do thc wo* ad thc siluctrc is not inodcd or offqed for slc (Sc.7044. Busins md Prcfsioro Codq Thc Contmctor's Lic6c taw do6 not apply to e om6 of thc pDpsty who builds or imprcv6 th@n, ud who do6 sch wotl himsclf or hmlf or through his or hq ou mpby6. providcd thar such improvqHns dc not intqdcd or oflqcd for slc. lf. howqq. thc tuiHing or imprcffit is $H within onc )â‚¬r ofcomplction, the Ovma Builda will have the hrdqr ofproving thd hc or she did not buiH or inprore the prcpoty for thc pruposof slc). ft, o o*no of thc popcny, m cxclusivciy contracting wirh hcascd contractoF to oostruct thc prcjcl (Se. 7044, Buine ird Proftsbn Codc, Thc Contrrctor's Liccnsc Law do6 not apply to a owns ofprcpcny who builds or imprcvcs thq@n, and who conancls for such prcjG{s with a Contruto(s) liccEcd puNwt to the ContBctor's Licâ‚¬e Law). -l arn exempt under Section- , B. & P.C. for this reason. Date:_ WORKERS' COMPENSATION DECLARATION I hereby afiinn under pâ‚¬nalty of perjury onc of thc following declarations: __l havc and will maintain a Certificate of Conscnt to Self-lnsure for workers'compensation. as provided for by Section 3700 of the Labor Code, for the perforrnance of the work for which the perrnit is issued. 'lrrand will maintain workcrs' cornpensation insurance. as required by Section 3700 of the labor Codc. for the pctformance of the work for which this pcrmit is issued. My workcrs' compensation insurance carTier and policy numh are: ,A C)c D Policy ra3 y1 dg Exoires:v ,/" r,/za ?. o 6 r*rrthar rn the performance of the work for which this permit is issued. I shall so as to become subject to the workers'compensation laws of California. and agrec that workers' compensation provisions of Section 3700 of thc Labor Code, I shall. forrhwith not ernploy any person in any manner if I should become subject to the comply with those provisions. * ,tu the WARNING: Failure to secure workers' compensation coverage is unlawful. and shall subject an employcr to criminal penalties civil fines up to one hundred thousand dollars ($100,000). in addition to the cost of compensation, damages as provided for Section -1076 of the Labor Code. interest and attorney's fecs. Orl"r. - I hereby affirm under penalty of perjury that I zun licensed under 9 (commencing with Sc.ction 7000) of Division 3 cf the Business and Professions Code, and rny license is in full force and effect. l,iccnse Number:Fss 8?3 Dare: 9,/ZrAozo contrector,i& -.ta. l, *;7- \- th@byafFmund6pqlaltyofpcrjuryth8!*ffifomccofthcworkbrwhichthispqnitb isucd (Sc. 3097, Civ. C.). Lcnder's Name: I-cndcr's Address: APPLICANT NECLARATION I ht:tb, aIlinn under penalty of perjury one of the following declarations: Dcrnolrtion Permits-Asbestos Notification Federal Regulations (Titlc 40, Par16) _Required Letter of Notification _-t cdiry that thc fed@l rcgulstiom rcgudisg ubqtos rqnoval ac not applicablc to this prcjtrt. 4 ,rtity tt xl have red rhis application and statc thal thc abovc infomation is corâ‚¬ct. I agre to comply with all City and County ordinuce ud State taws rclaring to building co$truction md h6cby authorize reprmtativG of this Cily ed County to atq upon thc above mentioned property for inspetion Applicant or r\gent Signature: Pcrmitee n&me t 2o?a Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloo r/VenUl nsu lati on Roof Sheathins Shear Wall Framinq lnsulation/Energy Drnruall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif. FINAL /o'/ Q -z I b*otz Gertificate of Occupancy Notes, Remarks, Etc.