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owNt:R lrutLt)t)r l)ut.cARA'iloN
<br />I herehy tllirnr under penxhy of pcrllrry thal I anr e\enrpt fron thc ( ()nlrrclon l-iccnse l;rw for the followrrg rea$n (Sec.7031.5
<br />IJusincss ^nd l,rcl'cssion Codc): Any Cily or County which rcquircs a frrmil lo conslrucl. allcr. improvc. demolish or rcpair rny
<br />stnlclurc.prir)rk)its issuarce.rls{,requrre\thcapnlicrntti)rsuchpernilk)lileasi8nedsliltcmenl lhatheorsheLsliceD*d pilrsuailt
<br />h thc pmvisionr ol lhc Conlracor's l.iccnscd Iaw (Chrptcr 9. Comrnencing with Scclion 7(X)(l ol l)ivision J ol lhe llusiness and
<br />P,1ilisst)nsCodc)orthuthc()rshcisc\enrptthcrrtionlaDdthebrsisfutlrallegedexenrpti(nr. Atyvi()htiulofScoiionT03l.5byriy
<br />rpplicrnt for x p.ntril subjccts the applicuDr ro r civil pcnilly ol'nol Ntre lhilil livc hundred dollflrs ($500).
<br />_1. as owncr ol lh+ prclEnv. or rny c,nplovces wilh wagcs as thcir solc aornpcnsilion, will do thc work and thc' sxuctrrc is not
<br />irilcdql or olTered for $le (Se.71I4.1, Business nnd Prrfessir[s (bdc: Thc Cr)ntrilct)r's Liccnse l-ru' does nol rpply k) ai owner oI
<br />tlrpN)Er1y wlf,,l{ild\orinrpR)vcstherdn!mdwlx)doessuchwor(hinlself(trlrcrselfrrrtlrrouglhirorherownempkryees,
<br />providcdlhnlsu(h irnprovclBnlsiuctrolintcndcdori)llirrcdli)rsnlc.ll,howcvcr,lhcbuildingorilnprovermntissoklwilhinonclur
<br />ofconl)letitr), llt Oulrer Builtlcr will hlve the burden of pn)vi,r8 lhal he or she (lid not truikl or inprovc the pnluy firr tlc purpr* of
<br />_1. as rrwner of the p()per1y, am cxclusiveh,conlrncting with Iicensed coDlr&k)r\ kr c()tr\lrucl lhe pft,je(l (Scc. 7(N4. Bu\iness
<br />rnd l\)tlssi(nlCode:TheContrrctor'sl,icen\cLawdoe\trolapplyttranowrcrofpr)perlywh{)build\orinrproveslhcreoil.
<br />rnd $,ho c(,nrrn(ls lirr \nch pr(,iccls with a C()nlrackn{r) liccnsc(l pur\uanl lo lhc Conlrrclor's Liccnsc Law).
<br />WoRK}:RS' ('oI\IPENSA'I'IoN
<br />l)ECl-i\RATION
<br />I hcrchy allirmunllcr pcnilrvl,l pcrjury(,nc ol tlrc li,lhrwhg tlcclurations:
<br />_l have iuxl will nuinlain a ('enificrte of Coosent to Selt.lnsure fi)r workcrr' conrpensalion, as pruvided for hy Section 3700 of the
<br />t-itx)r Co(lc, lirr lhe pcrlhrmancc ol lhc work lbr which lhc pcrmil ir issucd
<br />_lhaveandwillnHt(rillworkers conlpensatiotrinrurutrce,as rcquiredhySecti(xl:lT0OofthcLrhorCode,t?)rthcpedbrruurceof
<br />thc work litr which this IErmit is issucd. My workcrs' conWrnsati(,n inrurrncc cafricr arxl lx)licy nunrhkr ilc:
<br />h
<br />Pori"yN,u,t",,-1 LAI.38CVtlOO\ r:*o*",,, t)-3i-)cl()
<br />_l anr exenlln under SectioD-, B. & P.C. tbr this reasrrr.
<br />Scction l()76 of thc Lukrr Cotle, irleres aml alk,rrcy s lee\.
<br />_l ccrili thilt in thc lf,rlin-ouncc 0f lhc wolk ti)r which this pcrnlil is rssucd, I shall not cnllloy rny lL-rson in any nranncr
<br />so rs h huconr suhjccl x) thc workcrs' coilrpctrsntion hws ol Cnii lorsil, and rgrce thil i f I should h*cotrr suhjcct to I hc
<br />worlcrs' conrpcD\rtron pruvi\iors ol'Section 1700 ofthc Labr Cixle, I shill. tbnhwith conlply with rlp* provisi(rrs.
<br />WARNING: Fililurc to sccurc workcrs'c()n{Ensati(,n covcragc is unhwful. rnd shall subjcct an cnrl)loycr to criDlinal Fnaltics m(l
<br />civil liner un lo onc hundrcd thousilnd dollnrs (Sl(x).(II)), in xddition o thc cosl ol-cotrrpensalion. dilmnges ns provided for lhe
<br />a
<br />I)ECI,AR.\TIoN
<br />Ihcrchyillliilnnnd.rpcnaltyolncr.jurythatl0mliccnscdund(rprovi\ir)nolChrpr.r9(cdrnrrcncing
<br />(,l lhc Irusrncss ud P()lcssions Corlc. an(l n)y liccnsc is in full li,rcc ao(l clLct.
<br />l-rcr-osc -iceosc
<br />knder's Addrcss:
<br />APPI,ICANT DECI,ART\TIoN
<br />I lrreby afl-rrnr untler penalry of perjury oile ot thc followinB dcchrrl iurs:
<br />Denxrlition Perrrits-.\sbe\b$ Notification Federal ReSulations (Title.l0. Pail6)
<br />_lle(luired trtter of Notificntioo
<br />-JOJ)
<br />ccflif) thrl I hive rer(l lhi\ npflicrlio) and slnlc thrl lhe ilh)ve iilfornrilioo
<br />ordir)alecs ind Strtc Lilws rchti,rg to h!ilding constnlcli(D. ilxl hschy
<br />dtx)\'c mcnti()nc(l pfl)f-ny l-or inspcclion L.\pplicint or Ag(nl g
<br />P(,rnrilee nilnrr
<br />wilh Sccrhn 7(XX)) ol Division 1_
<br />,6L/
<br />CONSTRI.JCTION I,I.]NI)ING AGNNCY
<br />I hercby aflirm under Fnalty of Friury rhat lhere is a constnrcliotr lerilirg a8errcy tbr the performarce of the work li)r which rlts nermit is
<br />issucd (Scc. .l(l')7. Civ C.).
<br />lrtrdcr's Nirilc:
<br />_l lcaity lhul rhc Icrfuralreguhtir:rrs regardi"g rsbcslor rcnx,vrlurc n({ ilpl)licilb[. r(' rhis proicer.
<br />i\ eo[ecl. I agrcc to conlpl!
<br />reprc\eDlilives r)l' lhis City
<br />with .ll City rD(l Coutrly
<br />and couoly b ciller ulDn llE
<br />L-lJorO
<br />ID/SIG.COMMENTSSITE.WORK DATE
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsu lation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framinq 5-/o-zo o-( 1o;
<br />lnsulation/Enerqy .4,
<br />Drywall j-Jl'2o )r-W\tlt
<br />Ext./lnt. Lath "(\-/
<br />Brown Coat
<br />ft/asonry
<br />Pool Fence
<br />T-Bar 'hQ;r
<br />Handicap Req
<br />Deputv Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />I
<br />\ltalta Wr0U,FINAL
<br />Certificate of Occupancy l'
<br />Etc.Notes Rem
<br />r$\-I
<br />I
<br />Flev. 0B-0/-201 5
<br />BUILDING- !NSPECTOR RECORD
<br />frhtr .?PK. V.YUTlt)
<br />I
<br />IL
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