102106177 - Permit - Laserfiche WebLink

Home Browse Search

BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I h@by affm und6 pcnally of pcrjury that I m cxmpt from thc ContractoB' LiccN law for the following lten (Sc.7031.5 Busine ard Prcfsion Codc): Aoy City or Couty which rcquirs a pernit to coNtruct, altc, improvq &molish or rcpair oy structue, prior to its issuacc. also requirs thc applicut for such pmit to filc a signed statoot thar hc or strc i: licoscd pmt to thc provisioN of thc Contrutor's Liccnscd trw (Chaptq 9, Commcncing with Setion 7000 of Divisioo 3 of thc Buine ud PrcfsionsCodc)orthathcorshcisexmptthqeftommdthe basisfortheallegcdcxmption. AnyviolationofSâ‚¬lion703l.5byey #*#;il;J;ffiffi;H.#ffi*,**********", thc prcpqty who tuilds or improvc thson. ed who doB such wrt himsclf or hrelf or thrcugh his or ha om cmployce, providcd that such improvmb rc rct irtqdcd or olfqcd for slc. If, howoo, the hriHiry or improvqmrt is sld within onc )qr ofcompletior\ thc 0*46 Buil<k will harc thc hrdgr ofpoving tlr* hc or drc did mt hrild or improvc the popary for thc purposof eh). -1. r omq of the propqty, m exclsivcly contrac{ing $,ith licmsâ‚¬d contractoE to construcl thc prpjEt (Se. 7044, Bwin6 ud Ptofsbn Codc: Thc Contretor's Licsc Law doa not apply to o owna of prcpcnywho builds or ioprcve th6@n, ild who ontnds for such proj@ls with I Conracro(s) liccnscd pun@t to thc Corilractor's Licre Law). B. I hereby affrrm under penalty of perjury one of the following -l have and will maintain a Certificate of Conscnt to Self-lnsure for workcrs' compersation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which the pcrnrit is issued. -l have and will maintain workers' compensation insurance, as required by Section 3700 of the l-abor Code, for the performance of the work for which this pcrmit is issuod My workers' compensation insurance carrier and policy numh are: Annin. Policy Number: Expires: \J&"orjfy ttotin the psfomancc of thc work for which this fmit is i$ucd, I shall not @ploy my pc6on in any men6 rc ro to beome subjet to thc works' @mpqtsarion law of Califomia, ud agrc that if I should bcomc subjet to the wort6' compâ‚¬Ntion prcvisioro of Setion 3700 of thc Labor Code. I $all. fonhwith comply with thos prcvisiom. WARNINC: Failurc to suc work6' @mpeNarion @v@gc is unlawful. od shall subjet u ilploF to siminal pouhics md civil finq up to onc hudrcd thouud dollm ($100.000). in addition to thc cost of compcmtion. &mage r prcvided for the attorney's fees.4 I hereby affrm under penalty of perjury that I arn licensed 9 (commencing rvith Section 7000) of Division 3 of the Business and Professions Code. and my license is in full force and efFect. License Class: License Number: W I hdcby affm und6 penalty o f pcrjuy that thqc is a @ngruction landing agocy for thc pqfoIrrucc of the work for which this pqmit b issued (Se. 309?, Civ. C.). [:ndq's Nmc: Lcnder's Address: APII.ICANLDECI.AEAIION I barty affna unda penlty of pc{ury oac of the followiag dalanriore: Dmolition Pmits-Asb6tos Nodficatio! Fcdqal Rcgulatiom (Titlc 40, Pan6) -Rcquircd lrttc of Notificafion -l cotiry thd thc fcdoal rqulatiore rcguding rbctos rmoval rc not applicsblc to this prcjct. lA*tiry tfta I havc @d this applicstion and statc that thc abovc infomation is @ret. I agre to amply with all City ud Couty brdiamcc ud State t:m rclaing to building con$ructiorq md h6â‚¬by authorire rcp(â‚¬artativc of this City ud Couty to ot6 upon the above mentioned property for inspection ,a ' Applicant or Agent ' Permitee IL Zo "/ Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/Ve nUI n s u Iatio n Roof Sheathinq Shear Wall Framing lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif \ FINAL to ll Lt _hff4- Certificate of Occupancy t \v Notes, Remarks, Etc. _l I l\^....Contrector: R(os