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BUILDING. INSPECTOR REGORD <br />SITE.WORK DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION <br />I hscby aflim utrds pcrulty of pqjury thst I m cxempt from thc Contractos' Licm law for thc following twn (Se.7031.5 <br />Buinq ad Profsion Codc): Any City or Couty which rcquirc a pamit to costruct, alta. improve dcmolish or rcpair oy <br />structuq prior to its ismcq also rcquirG thc applicet for such Fmit to 6lc a signcd starmot thar hc or shc is licoscd pwanr <br />to thc provisiom of thc Coilractor's LicmEcd taw (Chsptq 9, Comocing with Setion 7000 of Division 3 of thc Bwins md <br />Prcfeions Codc) or that hc or shc is cxmpt thGfrom ad thc basis for thc alle8cd cxmption. Ary violation of Setion 7031.5 by ey <br />applicant for a pcrmit subj(ts thc applicant to a civil pmlty of not morc tha fivc hutrdr€d dollm (S500). <br />_1. 6 own6 ofthc properry, or my employe wirh waga c thcir slc composation, will do tlE wsk {d thc $ruclrc is not <br />intoded or ofrercd for salc (Ss.7044, Bsins md Profcssioro Code: Thc Contrac{or's Licffi law do6 not 8pply to a oms of <br />thc prcpcty who hrilds or imprcrc thmn. and who dos such wrl himsclf or hffilf or thrcugh hb or ha own cmploycc. <br />provided that such imprcv@ols rc not intqded oroffscd for sle. If, howm. thc huilding or imgormt is rcb within onc ]qr <br />ofcompletion, the Ownq Buikla will have thc hrd€n ofproving thrt hc or she did not build or imprcvc thc prcpqty for thc purporc of <br />sle). <br />_I. as owner ofthe property. am exclusively contracting with licensed contractors to construct the project (Sec. 7044. Busincss <br />and Pmfession Code: The Contractor's License Law docs not apply to an owner of property who builds or improvcs thereon. <br />and who contracls for such projeds with a Contracto(s) licensed pursuant to the Contractor's License [aw). <br />-l <br />arn exempt under Sertion-. B. & P.C. for this reason. <br />f\o lo. <br />WORKERS' COMPENSATION <br />DECLARATION <br />I hereby allirm under penalty of perjury one of the following declarations: <br />-l <br />have and will maintain a Certificate of Consent to Self-lnsure for workers' compensation, as provided for by Scction 3700 of the <br />Labor Code. fcrr the perfonnance of the wo* for which the permit is issued. <br />_l have and will maintain workers' comperuation insurance, as requircd by Section 3700 of the Labor Code. for the performance of <br />the work for which this permit is issucd. My workers' compensation insurance carrier and policy number are: <br />c*r'r, t 0 os*PcDe, T <br />Policy ooo zz t b-tl- ZL <br />_l cefliry that in thc pcrfomncc of thc work for which this pomit is issucd. I shall not mploy my peron in any mmnc <br />m c to beomc subjet to thc work6' compcnsation laws of Califomia. ild agE thal if t should b6ome subjet to thc <br />workc' compqvtion prcvisiom of Setioo 3700 of the tabor Codc, I dBn. fonhwith comply with thos provisioro. <br />\{ARNING: Failurc to wuc workm' compqrsation ovoagc is unlawful. od shall subjrct u mploycr to qiminal pcrEhi€s ild <br />civil finc up to onc hun&cd thousud dollm ($100,000), in addition to thc cost of compcMtiotr, dmag6 I providcd for thc <br />Sfftion 3076 of thc labor Codc, intqGt md attomsy's f6. t <br />Dare: '*-LT -Zt Applicant: }(€ llo s Lp e*ory?.A, o <br />LI <br />DECLARATION <br />I hereby affrnn under penalry of perjury that I am licensed under provision of Chapter 9 (commencing with Section 7000) of Division 3 <br />of the Business and Professions Code. and my license is in full force and effoct. <br />I <br />Licensectu*r' C-\f Licensc Nunrber: i ?t ttt <br />o ( conrracror: A/ I gtbt ? ar c,{l^rll-L7 ? <br />J] <br />CONSTRUCTION LENDING AGENCY <br />t hocby affm undc p.nalty of pqjury thar th6e is a @Etruction loding agmcy for the pqfomc. of the wofi 6r which this psmh b <br />isucd (Se. 3097, Civ. C.). <br />Lender's Namc: <br />Lender's Address: <br />APPLICANT DECLARATION <br />I hereby affrnn under penalty of perjury one of the following declarations: <br />Demolition Permits-Asbcstos Notilication Federal Regulations (Titlc 40. Part6) <br />_Required Letter of Notilication <br />_l certify that thc federal regulations rcgarding asbestos removal are not applicable to this project. <br />_l certify that I have read this application and state that the above with all City and County <br />and County to enler upon theordinances and State laws relating to building construction, <br />above mentioned property for inspection purposes. <br />Applicant or Agcnt <br />Permitee natne }(7- <br />rl,e L? -Z ( <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bfloor/Ve nUI n s u !atio n <br />Roof Sheathing <br />Shear Wall n\ <br />Framing :-27'.r4 yr&)\ <br />lnsulation/Energy \') <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Poo! Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />n <br />,^\ <br />FINAL Y-27n)Ulll-rr\\ <br />Certificate of Occupancy G'\-/ <br />Notes, Remarks, Etc. <br />-4 <br />Owner: