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BUILDING. !NSPECTOR RECORD <br />SITE.WORK DATE !D/SIG.COMMENTS I h6cby affirm unds poarty orpcrjrr *" ,"Ni"*i'Hl'fl'"1*ff11}* t* for the following ,*n (s4.7031.5 <br />BBin6s md Prcfeion Codc): Any City or Cowrty which requirc a pamit to oNtruct, altq. imprcvg danolish or rtaair uy <br />st$ctuq prior to its issumcc, alrc rcquira thc applicut for such pgrtrit to 6le a signcd statmot that hc or slE is licascd pEust <br />to the povisioN of thc Contrutor's Licmscd Law (Chapts 9, Commcing with Setion 7000 of Division 3 of thc Busincs ud <br />Prcfsios Codc) or that hc or shc is cxempt thacfrom ud thc ba3is for the allcged cx@ption. Any violation of Sdioo 7031., by uy <br />ffiffi#;d,J;ffiffi;ffi ffi *-il**********", <br />thcprcpsty whobuildsorimprocthon,edwho&ssrchwrthimselforhcclforthrcughhisorhoomcmployec, <br />providcd that such improvqn@ts rc rct intqdcd or olfsod for slc. I( how6, th€ buiEiry or improvffit is rcH within one 1an <br />ofcompl€tiorf the Owtrq Builda will havc thc hrdor ofpoving ttra hc or strc did mt build or improvc thc prcpqty for thc Fuposc of <br />#**rr,*tHs,',Hr:ir;:'L:ffi**T:iffi ffi ;*ffi :r,*ffi i,rTtriff "ly;l"T**Elrand who contmcls for such poj61s with a Contracto(s) licos€d pswt to the Cootraclor's LiccN Law). <br />-l <br />am exempt undcr Scction-, B. & P.C. for this reason. <br />Drte:ol o,r/ o r <br />WORIGRS'COMPENS <br />DECLARATION <br />I hereby affrm under penalty of perjury one of the following declarations: <br />_l havc and will maintain a Certifrcate of Consent to Self-lnsure for workers' compcrsation, as provided for by Section 3700 of the <br />Labor Code for the pcrformance of the work for which the pcnnit is issucd. <br />_l have and will maintain workcrs' compensation insurance, as required by Section 3700 of the l-abor Code. for the performance of <br />thc work for which this permit is issued. My rvorkers' compensation insurance carrier and policy number are: <br />Policy Numbcr: Expires: <br />ffi ccniry that in thc pqfomncc ofthc work for which this pcrmit is isued, I slnll rct mploy uy p6sn in my mona <br />\f c to baomc subjet to thc rcrtc'ompccstiotr lam of Cdifomia, ed agc that if I slpuld beomc subjct to thc <br />worlc' compcrsation povisiom of S€lion 3?00 of thc Labor Codc. I slull. forlhwilh smply with thos prcvisiou. <br />WARNING: Failurc to suc rcrk6' ompquation covogc is unlawful, ud shall subjet il mployq to qiminal poultic ad <br />civil fma up to onc hu&od thoMd dollG ($100,000), in addition to the cosc of compcNtion. damagc I prcvidcd for thc <br />attorncy's fees. <br />DECI.ARATION <br />I hereby affrm undcr pcnalty of perjury that I am liccnscd under provision of Chapter 9 (commencing with Scction 7000) of Division 3 <br />of thc Business and Professions Code, and my license is in full force and effect. <br />License Numbcr: <br />W <br />I hcby a[Im undc p€ialty of pcrjury thd thcc b a construc{ion knding agmcy for thc pafmmcc of rhc rcrL for which thb Fmil b <br />isucd (Sc. 3097, Civ. C.). <br />lrnder's Name: <br />Lcnder's Address: <br />APPLICANT DECLARATION <br />I hodry afiirm under penalty of perjury one of the following declarations: <br />Demolition Permits-Asbcstos Notification Federal Regulations (Title 40, Part6) <br />-Required <br />Later o f Notification <br />with all City and County <br />and County to enter upon the <br />above mentioned property for <br />Applicant or Agent **?l golQ\ <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bfloor/Ve nul ns u latio n <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Energy <br />Drnruall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />FINAL /A-{r->l 3-c /S nA.tae: Z'1 <br />Gertificate of Occupancy <br />Notes, Remarks, Etc.