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BUILDING. INSPECTOR REGORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DEICARATION <br />I hqcby aflim und6 p@alty of pcrjury that I m qmp ftom thc Contrrcton' Liccre trw for the follouing rtmn (Sc.7031.5 <br />BEins dd Prcfsion Code): Any City or County which rcquirc a pomit to @nstruct, 6ltq. imprcvg danolish or rtpair my <br />srucrc Fior to its isuocc. also rcquira thc applicmt for such pcndt to 6lc a signcd $d@6t that hc or slE b licascd pl,l!@t <br />to the provisiore of tlE Coilrrctor's Licoscd l"aw (Chapt6 9. Comcncing with Sstion 7000 of Division 3 of thc BEins md <br />hofsior Codc) or thd hc or shc is cxmpt thscfrom ed thc besis for thc allclcd q@ptioa. Any violation of Sdion 7031.5 by any <br />applicet for 8 psmit subjets thc .pplicant to s civil pcnally of not morc thil fivc hudrcd dollm ($500). <br />_1. 6 om6 of thc poparn or my mployG whh w8g6 6 thcir $h compcrEdioG will do drc wod( [d tlE srtutw is mt <br />intqdcd or offqcd for slc (Sr.7044. BBins md Profsioc Codc: Thc Contrac{tr's Licqe kw doB not eply lo m om6 of <br />thc propqty who tuilds or improvc tlsou and who doc $ch w* hirelf or harlf or tlrough his or ho om mploye, <br />providcd that such improvqurts m mt htqrdod or olfuod for sh. If, how, tlrc hrilding or impromt is rH whhin onc )@ <br />of cornpl*br\ thc o\mq BuiHr will haw thc hrda of pmviry dld hc or shc dil rct hild or ir4rorc thc popaty for ttrc puposc of <br />$le). <br />_1, as owner of the propcrty. am exclusivcly contracting with licersed contractors to construct the projed (Sec. 7044. Brsiness <br />builds or improves thereon.and Rof€ssion Code: The Contractor's Licensc Law does not apply to an owner <br />and who contracts for such projccts with a Contracto(s) licosed pursuant to Licensc Law). <br />_l am under B.&/r ZJ <br />I hereby affrrm under penalty of perjury one of the following <br />_l have and will maintain a Cenificate of Consent to Self-lnsure for workers' compensation, as provided for by Section 3700 of the <br />Labor Code, for the performance of the work for which the pennit is issucd. <br />_l have and will maintain workers' compcrsation insurance. as required by Section 3700 of the Labor Code, for the pcrformance of <br />the work for which this permit is issuod My workers' compensation insurance carrier and policy numbcr are: <br />Carrier: <br />Policy .f <br />_l certi& that in the pcrformance of the work for which this permit is issued. I shall not employ any pcrson in any manner <br />so asto becorne subject <br />workers' compcnsation <br />WARNING: Failure to <br />to thc workers'compensation laws of California" and that become subject to the <br />provisions of Section 3700 of the t-abor Code. I shall.with those provisions.i <br />seture workers' compcnsation coveragc <br />thousand dollars ($100,000), in <br />is unlawful. and an firploy€r to criminal po'ultics and <br />civil lines up to damages as provided for the <br />Section [abor intcrcst and attorney's fees. <br />( <br />I hereby aflirm under penalty of perjury that I am liccnsod provision of Chapter 9 (commencing with Sccrion 7000) of Division 3 <br />of the Business and Profcssions Codc. and my license is in full forcc and effect. <br />License Class: License Numbcr: <br />Dete: <br />W <br />I hwby affum unda poalty of pojury thst thrc is a @nstruction hnding ag@cy for the pqfoIrmcc of thc rcrk for uhich this psrnit is <br />issucd (S*. 3097, Civ. C.). <br />lrndq's Nmc: <br />APPLICANT DECL{IL{TION <br />I hereby aflirm under penalty of perjury one of the following declarations: <br />Demolition Perrnits-Asbcstos Notification Fedcral Rcgulations (Tille 40, Part6) <br />-Required <br />Lrtter of Notification <br />-l <br />certi& that thc lbdcral rqgulations regarding asbestos not applicable to this project. <br />with all City and County <br />above mentioned propcrty for <br />, enter upon thc <br />zoZl\Applicant or <br />and state that information is correct. I <br />and <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bfloor/VenUI ns u latio n tt Alt d <br />Roof Sheathing /?/ild E%ITA,Ka% <br />Shear Wall 1nflat l-Y[Hrt t116) <br />Framing <br />lnsulation/Enerqv <br />Drlnuall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Fina! Report <br />Flood Zone Certif <br />lt l/1 /n <br />FINAL lolil l9r brfr,*t ,{U <br />Gertificate of <br />Notes, Remarks, Etc. <br />-fl <br />^^-r-^^a^-. <br />Lcnder's Address: <br />Permitee name (print):_