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BUILD!NG. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DEICARATION I hqchy aflm undo pcralty of pcrjury that I m cxmpt fiom thc Cootrrcton' Liccm t:w for thc followiog rcmn (Sc.7031.5 Buins ard Profsion Codc): Any city or Couty which rcquira a pcrnil to o[truct. alta, improvq domlish or rcpsir ey struc{rc, Fbr to its ismcc, do rcquirc thc applicet for such pqmit to filc a signcd stal@6t th8I hc or slE b liccnscd pwatn to thâ‚¬ provisioB of thc Contrrctor's Licqsed lrw (Chapttr 9, Comocing with Sction 7000 of Division 3 of thc Buiae ud Prcfsions Codâ‚¬) or that hâ‚¬ or shc is qmpt thqcftom ud thc bosis for thc allcgcd q@flioo. Any violation of S6lbn 7031.5 by my applicut for 8 pqmit subjcts thc applicut to a civil pmlty of oot mrc thq fivc hundrcd dollus (S500). -1, o omq of the Fopcrty. or my cmployG with w8g6 I thcir rcle compqstion, wil do tlE wt atd thc sfutrc b mt intodcd or offqcd for slc (Se.7044, Buins ed ProfcssioB Codc: Thc Contraclor's Lic@ taw do6 not apply lo il oMq of thcpropqry whohuildsorimproeth@Gddwhodoeschwrkhimwlforhdforthrcughhisorhaommpbyâ‚¬, providcd thst such imFovqmB m mt intqrdcd or ollqcd for sh. lf, howq. thc tuildilu u inpromt is rcld whhin onc )qr ofcooplrbn, thc Owna Buil& will havc thc hudsr ofproving tM hc or shc did mt build or improre thc popcty br thc prpos of slâ‚¬). _1, a omq of thc propqty. m qcluivcly contrrcliog wirh licoscd conltrior to @nstruct thâ‚¬ projet (Sc. 7044, BNin6 ard Prpftsbn Code: Thc Contretor's Licw Law doq not Epply to e oms of propqly who builds or imprcvG lhq@n, md who antrrcts for such trojcts with a Contracto(s) licflsd pmwt to thc Contraclor's LiccE Law). I m cxcmDt utrd6 Setion-, B. & P.C. for this wn. WORKERS' COMPENSATION DECLARATION I hereby alTinn under penalty of perjury one of the following declarations: _l have and will maintain a Certificatc of Consent to Self-lnsure for workcrs' compensation, as provided for by Section 3700 of the Labor Codc, for the pcrformance of thc work for which the pennit is issued. _l have and will maintain workers' compensation insurance. as required by Section 3700 of thc Labor Code. for thc pcrformance of the work for which this pcnnit is issued. My workers' compensation insurance carriâ‚¬r and policy numh are: Policy Number: Expires: _t certify that in the pcrformance of the work for which this pennit is issued, I shall not employ any person in any manncr so as to become subject to the workers' compersation laws of California, and agree that if I should bccome subject to the workers' compensation provisions of Setion 3700 of the l-abor Code, I shall, forthwith comply with thosc provisions. WARNING: Failure to sccure workers' compensation coverage is unlawful. and shall subject an employc to criminal pouhies and civil fincs up to onc hundred thousand dollars ($100.000), in addition to the cost of compcnsation, damages .rs provided for the Section 3076 of the Labor Code, interest and attorney's fees. f lo to. LICENSED CONTRACTOR DECI.ARATION I hereby aflirm under penalty of perjury that I arn licensed undcr provision of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professiorrs Codc. and my license is in full force and effect. Liccnse Class: Liccnsc Number: CONSTRUCTION LENDINC AGENCY t hacby alfm undo Fnalty of pdjury thrl thqc is I orlstruc{ion lcnding agocy for thc pofomucc of thc wk for which this pqmit b isucd (Se. 3097, Civ. C.).t trdr's Nuc: Lender's Address: APPI ICANT DECLARATION I horby affirm under penalty of perjury one of the following dcclarations: Demolition Pcrmits-Asbestos Notification Federal Rcgulations (Title 40, Part6) -Requ ircd Later o f Notifi cation -l cstiry that thc fcdqat râ‚¬ulatioN rcgarding Bbetos rmoval uc not applicable to this prcj61. _l cdiry that I havc md this appliotion ad stdc rhat thc abovc infonndion is corâ‚¬t. I 8gr to @mply with all City md Couty ordireB md Statc taw rclatiry to tuildiry coErrudiorr ard holby authorir rcprstaivs of fiis City md Couty to dtq upoo thc abovc mationcd prcpcrty for iroperion purposc. Appllut or ABdt Sigmture: Dste:- Permitee nnme (rlrint): Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloor/VenUl n s u latio n Roof Sheathinq Shear Wall Framinq !nsulation/Enerqy Drywall Ext./lnt. Lath Brown Coat Masonrv Pool Fence T-Bar Handicap Req. Deputy Final Report Enqineer Final Report Flood Zone Certif tl .a\ FINAL /0lt>lA erruz;7 Certificate of Occupancy I Notes, Remarks, Etc. Date: Contrector:_