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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG COMMENTS OWNER BUTLDER DEI,CARATION <br />I hacb, affrm undo penalty of per;jury that I m qmpt from the ContBctoE' Liccrc t w for the followitrg t@$n (Se.7031.5 <br />Buine and Prcfsion Codc): Atry City or County which rcquirc a pomh to coEtruct. a.lto. improvc, damlish or rcpgir uy <br />structrc. lrior to its issuucc. also rcquic thc applicot for such pcnnil to fil€ 8 signcd starmat thal hc or slE b licqE€d pdsart <br />to thc Fovisiom of thc Contrutor's Licascd taw (Chaptq 9, Commcncing with Setion 7000 of Division 3 of thc Bwins md <br />PrcfsionsCodc)orthathcorshcisexmptth@ftomudthcbcisforthcalhgcdcxmption. AtryviolationofSetionT0ll.5byily <br />applicut for a pcnnit subjcts thc spplicilt to I civil pcmlty ofnot morc thao fivc hundrcd dollus ($500). <br />-1. <br />as owner of the property. or my employees with wagcs as thcir sole compensation, will do thc work and the stnrctue is not <br />intended or oflered for salc (Sec.7044, Business and Profcssions Code: The Contraclor's License Law does not apply to an owner of <br />the property who builds or improves theron and who does such wort hirnself or herself or through his or her own employecs. <br />provided that such improvoncnts arc not intended or offered for sale. I(, however. thc building or improvernent is sold within one )€ar <br />of complaion" the Orvner Buildcr will havc the btuden of proving thd hc or she did not build or improve the proprty for the purpose of <br />sale). <br />-1, <br />as owner ofthe propcfly, am exclusively contracting with licenscd contraclors to cons,truct the projec-t (Sec. 7044. Buiness <br />and Pnoftssion Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, <br />and who contracts for such projects with a Contracto(s) licerued pursuant to the Contractor's Liccnse l-aw). <br />-l <br />arn exempt under Section-, B. & P.C. for this reason. <br />l)qto' <br />WO RKER.S' COTT{PENSATION <br />DECLARATION <br />I hoeby affrrm under penalty of perjury one ofthe following declarations: <br />_l have and will maintain a Certificatc of Conscnt to Self-lnsure for workers' compensation. as provided for by Section 3700 of thc <br />Labor Codc, for the performance of the work for which the pennit is issucd. <br />!t nuu" and will maintain workers' compcnsation insurance, as by Section 3700 of the l-abor Codc, for the pcrformance of <br />and policy numbcr are:the u'ork for pcrmil is issued. My workers' compensalion <br />L <br />Policy <br />_l certi$ that in the perfonnance of the work for which this permit is issued. I shall not employ any pcrson in any manner <br />so as to become subject to the workers' compensation laws of California, and agree that if I should become subjcct to the <br />rvorkers' compensation provisions of Scction 3700 of the Labor Code, I shall. forthwith cornply with thosc provisions. <br />WARNING: Failure to sccure work€rs' compensation coverage is unlawful, and shall :rn and <br />civil fines to one hundred thousand dollars ($100.000), in addition to the cost the <br />Section Labor Code, intercst and attorney's fees. <br />o 3 -R <br />DECI.AEAIION <br />t hwby affrm undc p@lty of p6juy that I m [msod undr povision of Chapta 9 (om6cing with Sdlioo ?000) of Division 3 <br />of thc Buiae md Prcfsiom Codc, ud my licw is in full forcc and cffet. <br />a c3 Number: <br />b 0 6 I <br />W <br />I hmby alfnn undo pqalty of pqjury th8t thrc is 8 @Ntruclion l€nding ag@cy for thc pqfotlmcc of thc worl for which this pqmh is <br />issucd (Sa. 3097, Civ. C.). <br />Lcnder's Name: <br />knder's Address: <br />APPI TCANT DECI.ARATION <br />I hoeby affirm under penalty of perjury one of the following declarations: <br />Dernolition Pcrmits-Asbcstos Notification Federal Regulations (Title 40, Pafl6) <br />-Required <br />Lrtter of Notification <br />_l ceni& that thc <br />Hfr"*rrthat I have <br />federal regulations regarding asbestos removal are not applicable to this project. <br />read this application and state that the above information is correct. I agree to comply with all City and County <br />ordinances and State laws relating to building constructioru and representatives of this City and County to eflter upon the <br />abovc mentioned property for inspccrion purposes. <br />Applicartt or Agertl <br />Pcrnritee namc <br />- lo- <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bfloo r/VenUI n su latio n I e,. <br />Roof Sheathinq lol I ,vl7l <br />Shear Wall <br />Framinq <br />lnsulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Jtlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />.1 <br />FINAL t9 VLWL )VV O I <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />-+> <br />Expires:'/^//^Aq <br />to <br />,rr"-, fO - I .1 - & (, contractor'.)(.- <br />DWzry <br />I