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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG,COMMENTS OWNER BUILDER DEI{:{X?IION <br />I hmby alfum undo pcnalty of pcrjury thst I m cxmpt fiom thc Coilrados' Licw Law for thc following Iwn (Se.7031.5 <br />Buins and PrcfNiotr Codc): Any city or County which rcquirc a pcni to oEtruct, altq, improvq dstrolish or rcpair my <br />sructur, prior to its isue, also requiB thc applicmt for such p6mit to 6lc a signcd statdat thar hc or shc b licoscd pmuarr <br />to thc provisioB of thc Contractor's Licoscd Law (Chaptc 9, Conrmming with Satiotr 7000 of Division J of thc Buins ud <br />Prcfcsiore Codc) or that hc or shc is qmp th@from atrd thc b6sir for thc a.Uslcd amption. Any violatiotr of Setion 7031.5 by ey <br />spplicilt for a pcmit subjets the applir'&t to a civilp@ltyof not morc thfl fivc hundrcd dolles ($500). <br />-1, <br />r omq of thc popary, or my mplo)6 with wags s thcir elc @mpasatiotr, will do thc work ard thc strudrc is rct <br />intadcd or offscd for slc (Se.7044. BEine ud hofsioro Codq Thc Contraclor's Lic@ kw doB rct apply to m omq of <br />thc propsty who huil& or improrc ttE@n, ed who dG sch wrl hirelf or h@lf or thrcugh his or ha oM cmpby6, <br />providcd that such impromts rc mt intqrdcd or offacd for slc. lf, howq. tho buiHing or imprcwt is eld withh onc ,ur <br />of omp&riorL thc Olvno BuilCs wil turc thc hd6 of pmving dra hc or slrc did mt buiu or impiovc thc propqty for thE trrpo$ of <br />sle). <br />-1, <br />r oms of thc propoty, m crclusivcly conrraclitrg with licfiscd conracloB to @Gtruct tlE Foj6{ (36. 7044, &tsirc <br />md Proft*sbn Codc: Thc Contraclor's Licsc Law doe not apply to u owno of propqty who builds or improvB ths@rL <br />md who coilracls for such Fojets with a Contmto(s) licaMd p6wt to thc Contrsdor's Licffi Llw), <br />-l <br />m cxcmpt udq Setiotr-. B. & P.C. for this rruon. <br />Drtc _ O*ns' <br />YAEXEESSOMfJNIAIIAN <br />DECI.ASAIION <br />I hocby alfim undo pcna.lty of pojury onc of the followhg delamtioa: <br />_l havc ad will mintsin a Cdificatc of CoMt to Sclf-lEurc for workn' compqxaion, c prcvidcd for by S€1iotr 3700 of thc <br />kbor Codq for thc pqfoImcc of thc work for which thc pqmit is isucd. <br />_l havc and will maintain workm' compcEation iEwecq 6 rcquired by S*tion 3700 of thc tabor Code for thc pa'fomocc of <br />the work for which this Frmit is isuod- My workc' ompqrsatioo iroumcc mia ald policy numbo rc: <br />Policy Number: Expires: <br />_l ccrri& that in the performance of the work for which this p,ermit is issued, I shall not employ any pcrson in any manner <br />so as to become subjcct to the workers'compcrsation laws of California, and agrec that if I should bccome subject to the <br />workers' compensation provisions of Section 3700 of the l-abor Code. I shall. forthwilh comply with those provisions. <br />WARNTNG: Failure to secure workers' compensation coverage is unlawful. and shall subject an snployer to criminal porahies and <br />civil fines up to one hundred thousand dollars ($100,000). in addition to the cost of compensation. damages as provided for the <br />Section 3076 of the Labor Code, interest and attorney's fees. <br />Drte: Applicant <br />LICENSED CONTRACTOR <br />DECI,ARATION <br />I hereby affrm und€r penatty of pcrjury that I am licensod under provision of Chaptcr 9 (cornmencing with Secrion 7000) of Division 3 <br />of the Busincss and Professions Code, and my liccnse is in full force and effect. <br />License Class: License Number: <br />Dete: <br />W <br />I h@by 8ffm mdq pcrElry of pqjury that thft is a @nstruction Loding sgocy for the pqfollmcc of thc mrk for which this pqmit b <br />isucd (Se. 3097, Civ. C.). <br />ladq's Nmc: <br />Lender's Address: <br />APPLICANT DECLARATION <br />I hereby affinn under penalty of pojury one of the following declarations: <br />Demolition Perrnits-Asbcstos Notification Fcdcral Regulations (Title 40, Part6) <br />-Required <br />Letter o f Notification <br />-l <br />cqtiry lhat thc fcdGal rcgulatioE r€gardiq abetos rmoval uc not applicablc to this prcj€l. <br />_l cdi8, rhsl I havc rad thb applicstion dd statc thrr th€ abovc infonnation is con€{. I 8gE to @mply with all City ud County <br />ordimcB ud Statc taw rclaling to building snstructioil ed hqcby authorirc rc?rstarivB of thb City md Couty to ot6 upon tlE <br />abovc mtioncd prcpsry fu irepetion purpos <br />ADDllotrt or Alat Slqmt[rc: Drle <br />PemllE um. (DrlDtl: <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bfloo r/Ve nul n s u latio n <br />Roof Sheathing <br />Shear Wall <br />Framing <br />lnsulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />I <br />FINAL tA //4 h,Lql h <br />Certificate of Occu pancy tt <br />Notes, Remarks, Etc.