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SITE-WORK DATE ID/SIG.COMMENTS Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/Ve nUl n su latio n Roof Sheathinq Shear Wall Framing lnsulation/Enerqy Drywall Ext./!nt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif t/,-_ FINAL SfLLltt>.\E{ 7L ) Certificate of Occupancy tl Notes, Remarks, Etc. i,- owN t,lR Iltr I LI)Ell l) ol.('A lt^'rloN I h6eby affim unde pmalty of pcrjury thal I m cxmpl fiom the Contraclor' Liccnse law for thc following rcmn (Se.7031.5 Busins ad Prof*ion Code): Any City or County which requira a pornit to construct. 8ltq, improve, danolish or rqxir.uy structurq prior lo its issuoce. also requirc thc applicmt for such pmnit to filc a signcd stalmmt that hc or shc b liccn*d pm'uut to thc provisioN of the Contractor's Licensed Law (Chapl6 9, Commcncing with Sation 7000 of Division 3 of the Busins md Professions Code) or that he or she is exempt thqcfrom ud thc b6sis for thc allcgcd exmption. Any violation ofSetion 70-3 I .5 by any applicantforapflnilsubjststhc applicantloacivilpemltyofnotmorethufivchundreddollus($500). _1. as owner of the property. or my employees with wages as their sole cornpensation. rvill do the work and the structure is not intended or offered for sale (Sec.7044. Business and hofessions Code: The Contractor's License Larv does not apply to an orvner of the propoty rvho builds or improvcs thermn. and rvho does such rvork himself or herself or through his or her orvn ernployees. provided that such improvanents are not intended oroffered for sale. lf. however, the building or improvement is sold within one year of conrplaion. the Orrner Builder will have the burden of proving tha he or she did not build or improve the propoly for the purpose of sale). _1. as owner of the property. an exclusively contracting with licensed contractors to construct the project (Sec. 7044. Business and hofcssion Code: 'l'he Contractor's License Larv does not apply to an o\r'ner of property rvho builds or improvcs thereon. and rvho contracts for such projects with a Contractor{s) licensed pursuant to the Contractor's License Larv). -l arn exempt under Section-. B. & P.C. for this reason. Dale: Owner:- WO RK IiILS' CONT PENSA'I'ION DECLARA'TION I hereby affrrrn under penalty of pojury one of the follorving declarations: _l have and u,ill maintain a Certilicate of Consent to Self-lnsure for rvorkers' conrpensation, as provided for by Section 3700 of the Labor Code, for the perlonnance of the rvork for which the pennit is issued. -l hal'e and rvill rnaintain workers'lnsurance. as by Section 3700 of the Labor C-ode. for thc perfonnance of the work fior this pennit is iryUed.rj and p.rlicy number are: w C A Policy -l cerrify that in the performance of the rvork for which this permit is issued. I shall not einploy any person in any manner so as to become subject to the workers'cornpensation larvs of ('alifumia. and agree that if I should become subject to the rvorkers' compensation provisions of Section 3700 of the lahr Code. I shall. forrhrvith cornply with those provisions. pelralties andWARNING: Failure to secure rvorkers' cornpensation coverage is unlau'fu1. and shall subject an onployer to crirninal civil fines up to one hundred thousand dollars ($100.000). in addition to compensation. darnages as provided for the attorney's fees. DFCLARATION I hercby affinn under penalty of perjury that I arn licensed under provision of Chapto 9 (cornmencing with Section 7000) of Division 3 of the Business and I'rofessions Code. and rny license is in full force and effect. License b Dale:oA-- contrnc,or4 CONSTRUC'ITON LFNDING ACENCY I hercby aflirm under penalty otpcrjury that thtr is a comtruction lmding agocy for the pqfonnuce of thc wrk for which lhis Pqnit i3 issucd (Sc. 3097, Civ. C.). Lender's Name: ooortaon, pgclaru{"rloN I hereb), affinn under penalty of perjury one of the following declarations: Demolition Permits-Asbestos Notification Federal Regulations (Titlc 40. Part6) -Required Lrtter of Notification _l certify that the federal regulations regarding asbestos retnoval arc not applicable to this project. -l certify that I have read this application and statc that ordinances and State Larvs relating to building above rnertioned property for inspection Applicnrrt or Agent Signalrrre: Perrnitee nanre BUILDING. INSPECTOR RECORD \