101105902 - Permit - Laserfiche WebLink

Home Browse Search

BUILDING- INSPECTOR RECORD SITE-WORK DATE !D/SIG.COMMENTS OWNER BUILDER DELCANATION I hcrcby affirm undcr pnalty of pcrjury lhat I m cxcmpi fom lhc Conhacto6' Licens ljw for thc following rcasn (Scc.7031.5 Busincss ard Profcssion Code): Any City or County which rcquircs a Jsmit lo onslrucl. alter. improvc, demlish or Epsir oy structuc. prior to its issurec, alrc rcquircs thc applicant for such Frmit to file a signed statemnt lhsl hc or shc is liensd pursuant ro lhe prcvisions of thc Contractor's Liccned lrw (Chrptcr 9. Comrcncing with Sstion 7000 of Division 3 of the Busiress and PrcfcssionsCodc)orthathcorshcisexemptthcrcfromandthcba$isforthcalhgedcxcmption. AnyviolationofsetbnT03l.5byany applicantforapcmitsubjcctsthc rpplicanltoacivilpenallyofnottrcrcthelivehundrcddollus($500). _1, as owncr of lhc propcrty. or nty cmployccs with wagcs as thcir solc conlpcnsation. will do tlrc work and thc structurc is not intendcd or oll'crcd lbr salc (Scc.7044. Busincss and Profcssions Ctdc: Thc Contractor's Licensc Law does not apply to an owner of thc pro;rcrty who builds or irnprovcs thcrcu, and who drrcs such work hirnsclf or herself or through his or hcr own cnrployccs. providcd that such irnprovcnrcnts are not intcndcd or ofli:rcd for sulc. lf. howcvcr. thc building or irnprovcrncnt is sold within one ycar of complction, thc Owncr Buildcr will have the burdcn of proving that hc or shc did not build or inprovc thc propcrty for thc purposc of salc). _1. as owncr of the propcrty. am cxclusivcly contracting with liccnscd conlraclors to construct thc projcct (Scc. 7W, Busincss and ftrofcssion Code: Thc Contractor's License Law docs nol apply to an owner of propcrty who builds or improvcs thereon. and wh<l contracts for such projccts with a Contractor(s) liccnscd pursuant to the Contractor's Liccnsc [:w). -l am cxcmpt undcr Scction-, B. & P.C. for this rcason. Date: Owner:_ WORKURS' CON I PI,NSA'tI()N DIICI IITATION I hcrcby affirrn undcr pcnalty of pcrjury onc of thc following declarations: -l havc and will maintain a Ccrtificate of Conscnt to Selt'-lnsurc firr workcrs' compensation. as providcd for by Scction 3700 of thc Labor Codc. frrr thc pcrformancc of thc work tbr which thc pcrrnit is issucd. -l have and will nraintain workers' compcnsatiorr insurancc. as rcquircd by Scction 3700 of thc Lrbor Codc. for thc pcrformance of thc work lbr which this pcrrnit is issucd. My workcrs' compcnsation insurance carrier and plicy nunrbcr are: Policy 6'7 ( _l ccrtify that in thc lrcrformance of thc work for which this pcrmit is issued. I shall not cmploy any pcrson in any manncr so as lo bcconrc subjcct to the workers' compensation laws of California. and agree that if I should bccoutc subject to thc workers' compensation provisions of Section 3700 of thc l.ahlr Codc. I shall.those provisions. WARNING: Failure to sccurc workers' compcnsation is unlawt'ul.all and civil lincs up to onc hundrcd thousand dollars in adtlition to the Scction 3076 of thc Latnr Codc. interest and attorney's I I hcreby alfirm undcr Jrcnalty of perjury that I arn liccnscd provision of Chaptcr 9 (commcncing with Scctiott 7m0) of Division 3 of the Busincss and Profcssions Code, and my licensc is in full force and effcct. Liccnsc Date:I I elo ( "/ '[ >l I hcrcby afllrm undcr pcnalty of pcrjury that thcrc is a construction issucd (Scc. 3097, Civ. C.). lrndcr's Namc: agcncy for the pcrfbrmancc ol'thc work ltrr which this pcrmit ls [.cndcr's Addrcss: APPLICANT DECLARATION I hcrcby all-rnn undcr pcnalty of perjury onc of thc following dcclarations: Dcmolition Pcrmits-Asbcstos Notification Federal Rcgulations (Titlc 40. Part6) _Rcquircd lrtter of Notification ruccrtity that lhc lbdcralrcgulations rcgarding asbcstos rcnroval arc not applicable to this projccl. corrcct. I agrcc to cornply with all City and County abovc nrcntioncd propcrty for Applicnnt or Agent I)ernrilce nilnre thal thc lo entcr upon thc Set Backs Forms/Stee!/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/Venill nsu lation Roof Sheathinq Shear Wall Framinq !nsulation lEnerqy Drywall Ext./lnt. Lath Brown Coat N/asonry Pool Fence T-Bar Handicap Req. Deputy Final Report Enqineer Final Report Flood Zone Certif FINAL Certificate of Occupancy Notes, Remarks, Etc. /â‚¬R,r't /T O4rucâ‚¬Lâ‚¬D I /cfi- -trD t/)/ Io Dnre: // ?/ 2/ul7