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INSPECTOR RECORD <br />t <br />SITE.WORK DATE ID/SIG.COMMENTS OWNFR iUILDf,R DELCANATION <br />I hcby affim und6 JEnah]- of lEfjur.v that I am ermpt f(m thc Conhactos' Lissc Law ftr lhc follNing 6on (Sc.7031.-s Busin6s <br />and Profcssion ('odc): Any City or County shich rcquic a pcfirit to NNtruct. alt6. impmvc. dmlish or rcpair .ny smcluc. prior to its <br />issuancc. also Equi6 thc applicant for such pcrinit to lilc a si8trd stat.mnt lhat hc or shc is lic@d puEu.nt to thc pmvisioE of thc <br />('onmcrtr's l,icdscd law (Chapt6 g. cmmcncing wilh scrim 7000 of Division -l of thc B6in6s and Pmfsims Codc) q that hc q <br />shciscxmptthGfrmandth.b6isforthcallcged.imption. AnyviolationofscctionT0-!l.5byeyapplicantffispcmitsubjcBthc <br />applicant to a civil pdalty ofnot morc than fivc hundrcd dollaE (3500). <br />f,o l, as orrner of thc pmpcrty. or my mployc with 1vag6 as thcir $lc compcnetio. will do thc wat and th. stuctuE is m intdd.d <br />or off6.d for Ml. (Se.7044. Busin6s and Prefcisio6 Cod.: Thc Cont6clor's l,icosc [.w d(6 not apply to an @ntr of thc propsty <br />Nho huilds o imprN6 thqmn. and who dG such rvori himsclf or hmclf or thrcugh his or htr own mployc, providcd that such <br />imFs,qnors e not intcndcd tr offdld ftr sle. If. hwaa. thc building tr improvcmt is sold within m y@ of mplctio. dE <br />OM6 Buildcr will ha1,c rhc hrd6 of F$ing thal hc d shc did d build c impro'. lhc prcp.rty fG 0E BrD(E of slc). <br />YESI. a. o\\'ner of the prop€ry-. am exclusively contracting rvith licensed contractors to construct the project (Sec. 7M4. Busincss and <br />Itnfession Code: The Contractor's License Lau' does not apply to an owner of property who builds or improves thereon. and <br />rvho contracts for such proiects with a Contracto(s) licensed pursuant to the Contractor's License [,aw). <br />N-o-l ., exempt under Section . B. & P.C. for this reason. <br />WOR.KTRS' COIIIPf,'NSATION NFCI ARATION <br />I hereby affirm under penalty of perjury one of the follorving declarations: <br />No I h.r'. and u,ill maintain a ('errificate of ('onsent to Self-tnsure for s'orkers' com;rcnsation. as provided for by Section 3700 of rhe <br />l.abor (-ode. for the perfonnance of the rvork fior which the pennit is issued. <br />YES <br />I have and will rnaintain rvorkem' comp€nsation insurance. as required by Section 1700 of the Labor Code. for the performance of the <br />rvork for which this perrnit is issued. My rvorkers' compensation insurance carrier and policy number are: <br />STATE COTIPENSATION INSURANCE FUND('anier: <br />0064755 <br />Policy Number: _ <br />ozt19t2022Irpires: <br />NO <br />I cerrifo that in the performance of thervork forrvhich this permit is issued. I shall not employ any person in any mann6so <br />as to beconre subject to the rvorkers'compensation larvs of California. and agree that if I should become subject to the workers' <br />compensation provisions of Section .1700of the l-abor ('ode. I shall. forthrvith comply rvith those provisions.. <br />IVARNlNG: Failure to secure rvorters'comperlsation coverage is unlarvful. and shall subiect an employer to criminal penalties and civil <br />fines up to one hundred thousand dollars ($100.000). in addition to the cost of compensation. damages as provided for the Section 3076 <br />of the l.atxr Code. interest and attomev's fees. <br />LICl-NS1'N ('ONTRA('TOR NTCI AR.ATION <br />I herehy,alTinn under penalty of periury that I arn licensed under provision of Chapter t) (commencing rvith Section 7000) of l)ivision .1 of <br />the Business and Professions ('ode. and ml license is in fi.rll force and effect. <br />BAC30 <br />l-icense ('lass:984655 <br />_ l.iccnse Nurnber <br />('ONSTRTICTION LFNDING AGENC}' <br />I herehy affinn under penalty of periury that there is a constnrction lending agency for the performance of the work for which this permit is <br />issued (Sec. 3097. Civ. C'.). <br />Lender's Name: <br />[,ender's Address: _ <br />APPT ICANT DE('I AR/ATION <br />I heretry aftinu under penaltv ol'perluw one of the followrng declarations <br />[)enmlrtron Pernrits-Ashestos N<'rtrfi catron Federal Regulatrons (Trtle 40. Part6) <br />No_ Required l.etter of Notifi cation <br />"tt t certi$/ rhar rhe federat regulations regarding asbestos removal are nol applicable to this pro.iect. <br />YEs I certifu that I have read this apptication ancl state rhat the atnl'e information is correct. I agree to comply with all City and County <br />ordinances and State Larvs relating to building construction. and hereby authorize representatives of this City and County to enter upon th€ <br />atnve mentioned property for inspection purpos€s. <br />Reroof I <br />Roof (Diaphragm Sheathing/Frame)aln-lqt ,J*z.o <br />Structural Final <Ullb-,{ffizc <br />PIumbi <br />Under Floor I Under Slab <br />Rough <br />Shower Pan / Tub Test <br />Water Service <br />Sewer / Sewer Cap <br />Gas Air Pressure Test <br />Plumbing Final <br />Electrical <br />Service (Meter I Panel) <br />Grounding / Bonding <br />Rough <br />Electrical Final <br />Mechanical <br />Gas Air Pressure Test <br />Rough <br />Piping (HW, CW, etc.) <br />Exhaust Ducts <br />[Mechanical Final <br />Notes, Remarks, Etc. <br />D