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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION <br />I hereby affum undq penalty of perjury that I m qempt ftom the CotrtractoB' Licffi taw for the following rwn (56.7031.5 <br />Buines ad Profeion Code): Any City or County which requiG a pfinit to sGtruct, alta, improve, dmolish or rrpair my , <br />struc1ure. prior to irs isuace, also require the applicmt for such pemit to filc I signed statmmt thar lrc or shc is liceNcd pmuant. <br />to the previsioc of the Contractor's Licensed law (Chapta 9, Commcncing with Sstion 7000 of Division 3 of the Busincs md <br />Prcfesions Code) or that he or she is q€mpt thq€fiom md the b6is for thc alleged exemption. Any violation of Setiori7o3l.5 by any' <br />applicantforapmitsubjctstha appticilttoacivilpflaltyofnotmorethefivehundreddollus($500). <br />_1, c owncr of the pro6y. or my mploles with wag6 s thcir $le compffation, will do the work fld the struclrc is mt <br />int@dcd or offqcd for nle (Se.7044. Bwin6s ild Profsiore Code: The Contractor's LiceN law do6 not apply to il oMs of <br />the prcperty who builds or improvc ths@n, ad who do6 swh wrk him3clf or hmelf or thrcugh his or ho om mploys, <br />provided that such improvffints re rct intmd€d or olI6€d for ele. lf, howryq, the building or improvmt is rcld within onc )qr <br />ofcomplcion the Owner Buiklq will have the fudm of proving thrt he or she did rct build or improvc the prcpqty for tlrc purporeof <br />ele). <br />-1, <br />I oMs of the prcpaty, m uclusive ly contracting with licfficd contractoE to coGtruct the projsr (Ss. 7044, B6ins <br />ild Prcftssion Code: The Contrctor's License Law do6 not apply to u ownq of prcpqty who builds or imprcves thqsn. <br />and who contmcts for such projtrts with a Contrac{or(s) liceNed pu6@t to the Contmclor's Licffi Law). <br />-larnexemptunderSection-,B.&P.C.forthisreason.O*ner' <br />WORKERS' COMPENSA <br />DECLARATTON <br />I hereby affirm under penalty of pajury one of the following declarations: <br />_l have and will maintain a Certificate of Consent to Self-lnsure for workers'compensation, as provided for by Section 3700 of the <br />[,abor Code, for the performance of the work for which the pennit is issued. <br />)-fhave andIthe work for <br />3700 of the Labor Code, for the performance of <br />and policy number are: <br />le/toLL <br />Policy Number: f - Y- -t - .l Expires:7L7-Gq L f <br />_l cqtiry rhat in the poformana of the work for which this permit is issued, I shatl not mploy any pmon in any mmno <br />s 6tobeom€subjsttothework6'compsationlawsofCalifomia,edagr€thatiflshouldbcomesubjettothe <br />woil(m' compeMtionprcvisiomof Scction3T00ofthc LaborCodc, I shall. forlhwith@mplywithrhosprcvisiom. <br />WARNING: Failurc to sue workqs' ompemation covmge is unlawful, ud sha.ll subjwt u flplols to qiminal perEltie ad <br />civil lmes up to one hudred thoMd dollm ($100,000), in addition to thc cost of compcMtion, dmages 6 providcd for thc <br />Section 3076 of the Labor Code, interest and attorney's fees. <br />noro. tf - L tr-1 ( <br />I hereby affirm under penalty of perjury that I arn licensed 9 (cornmencing with Section 7000) of Division 3 <br />of the Business and Professions Code, and my license is in full force and effect. <br />B lcla) l,f <br />License Number: <br />D*", q-L F'L I <br />CONSTRUCTION LENDING AGENCY <br />I hreby affirm unds penalty of pqjury that th6c b a corctruction lcnding agocy for the pafomace of the work for which this psmit is <br />issued (S(. 3097, Civ. C.). <br />Lender's Name: <br />APPLICANT DECLARATION <br />I hoelry affinn under penalty of perjury one of the following declarations: <br />Demolition Permits-Asbestos Notification Federal Regulations (Title 40, Part6) <br />_Required Letter of Notification <br />_l cerri& that the federal regulations regarding asbestos removal are not applicable to this project. <br />-l <br />ceniry that I have rod this application and state thst thc abovc infomation is con*t. I agre to comply with all City and County <br />ordinancG ild State liws relating to building comtruaioq md hoeby authorire repr€mtativ6 of this City md County to 6ts upon the <br />above mentioned propefty for inspection <br />Applicant or Agent <br />Permilec namc €cz l{ <br />f)oln' <br />,{ -Z/-1 | <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bfloor/VenUl n s u latio n <br />Roof Sheathing <br />Shear Wall <br />Framinq <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />[/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />F!NAL P-ll-LL Lt-r T. <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />Lender's Address: