101107017 - Permit - Laserfiche WebLink

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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG,COMMENTS OWNER BUIII)ER DELCARATION I hqcby aflm undo penalty of pcrjury thst I m qmpt fiom thc Contrsctots' Liccre [rw for thc following ren (Se.7031.5 Bwine and Prcfcion Codc): Any City or County which rcquiro a pcmit to conslrucl, altq, improvc &nolish or rcpoir my structurg prior to its iswcq also rcquirc thc applicut for such pcmit to filc a signcd statmot thst he or shc is licascd pw{l to thc provisioc of thc Contretor's Liccnsed t:w (Chapt6 9, Comocing with Setion 7000 of Division 3 of thc BBirc md Prcf*ioro Codc) or that hc or shc is qcmpt thqcfrom ad thâ‚¬ basis for thc alleged umpion Any violation of S@tion 7031.5 by any applicmtforapo'mhsubjetsrhc applicettoscivilpflaltyofnotmorethufivchundrcddollm($500). _1, s om6 of thc popary. or my mplolB with wag6 s thcL $lc @mpcttsatioo, will do thc mrt md thc $tuctw b rct intqdod or oflkcd for slc (Sc.7044. Buine ud Profsioro Codq Thc Cont actor's Liccre kw do6 not apply to e om6 of thc propqty who builds or improrc ttu@n, srd who do6 och mil himsclf or hcclf or thrcugh his or ho om mploye, prcvidcd thst such impowrrcnts rc mt intqrdcd or oIH for sh. If. hoPâ‚¬E, ttE buiHiry or irprovqmt is oH withh onc )E of ompftrb]L thc Oryna Buiklr will haw ttrc hr&r of poving 0u hc or shc dil mt bild or hprove thc popcty for thc prpo* of elc). _1, ils owncr of the property, arn cxclusively contracling with licensed contractom to construct thc project (Scc. 7044, Business and Prcfession Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a Contractor(s) licaued pursuant to the Contractor's License l-aw). -l am exempt undcr Section-, B. & P.C. for this reason. Dolo' WORKERS' COMPENSATTON DECI,ARATTON I hereby alTirm under penalty of pcrjury one ofthe following declarations: _l have and will maintain a Certificate of Consent to Sclf-lnsure for work6s' compensation, as provided for by Section 3700 of the Labor Code. for the performance of the work for which the permit is issued. -l havc and will maintain workers' compcnsation insurance, as required by Scction 3700 of the Labor Codc, for the pcrformancc of the work for which this permit is issuod My workcrs' compâ‚¬nsation insurance carria and policy numh arc: 9c t( PolicyNr.b"r' -- q ZS f;5 qB Expires:on I oclzoAn _l ccrlify that in the performance of the work for which this perrnit is issued, I shall not employ any person in any manner so as to become subject to the workers'compcnsation laws of California, and agree that if I should become subject to the workers' compansation provisions of Section 3700 of the Labor Code, I shall. forthwith comply with thosc provisions. - WARNTNG: Failurc to secure workers' composation coverage is unlawful. and shall subject an onployer to crimind petnlties and civil frnes up to onc hundred thousand dollars ($100.000). in addition to the cost of compensation. darnages as provided for the Section 3076 of the t^abor Crde, interest and attorney's fecs. \lna dLv LLto I cl+r D F-l ta Ilqto. I hercby affirm under pcnalty of perjury that I arn licensed under provision of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and nry license is in full forcc and efkct. License ,C- Nurnber:1o5965cl,,,. - (olqlzt HTJ L W I hwby atfm undo p@alty of pcrjury thEt thc is a @ns(ruction lcnding agocy for thc pcfomcc of thc work for which this psrnit b issucd (Se. 3097, Civ. C.). Lender's Name: I-ender's Addrcss: APPLICANT NECI {RATION I hercby affirm under penalty of perjury one of the following declarations: Demolition Permits-Asbcstos Notifrcation Fcderal Regulations (Title 40, Part6) -Requ ired lrtter o f Notifi cation _l ccrtify that the federal regulalions regarding asbestos removalare not applicable to this project. _l certi& that I have read this with all City and County and County to entâ‚¬r upon theordinances and State laws above mentioned property for Applicant or Agent Fr&\)Dete:_ Pemlteumc(pdnt)l Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloo r/Ve nUl ns u lation Roof Sheathinq lu -O-Lt JL1r Shear Wall Framinq Insulation/Enerqy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif .^ FINAL lo-,-Ll tt-ur (1\', Gertificate of Occupancy \.r7 Notes, Remarks, Etc. Owner:_