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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS owNuR Ittilt,l)t'lR t)u,t,cARA'ItoN <br />I hercby afnrnr under penalty of per1ury that I anr exempt lrom the Cbntractonl License Law for the following ."orJi (S...lElt.-s' <br />Ilusiness and Prolesri()n Codc): Any City or County which rcquircs a lfnnit lo conslrucl, ahcr, irnprovc. dcmlish or repair any <br />struchre.priork)its issuancc.alsorequirestheapplicantlbrsucl)pemlitmfileasignedslalemetrl thrtheorsheislicenscd pursuanl <br />to lh(' pmvisions of llE Contr&clor's Liccnscd lnw (Chaptcr 9. Commcncing with Seclion 7UX) of l)ivision 3 o, the Busincss and <br />ProtessiotrsCode)orthrtheorsheisexemplthereftonrandthebasisfbrtheallegedexenrptiur. AnyviolatiooofSectionT03l.5byany <br />npplicanr for a pcrmir subjecrs rhe applicant lo n civil perul(y of nol rrcre thrn five hundred dollars ($5{x)). <br />_1. as owncr Dl'thc proJrcny. or rny cmployees wilh wages as thcir \olc compcn$tion, will do lhc work ard thc slrcturc i{ mt <br />iflerxled or ollered for sale (Se.?(N4. BusiDess end Pn)fessions Code: The Conlftclor's Liccnse I"aw docs nol npply to an owner of <br />thepn)Fny wlx)buildsorinprowslhcHnlntlwhod@ssuchworkhimselforlErselforlhroughhisorherowtremployees, <br />providcdth{t such impnrverrcntseenotintcndcdoroll'credl'orsalc. ll,howcver,lhebuildingorimprovemntissoldwirhhoncycil <br />ofconpbli(n\ th. Owrrr Builder will havc thc burtlen ofpmving thu he or she did mt build or impruvc tlE pmp.ny for llE purpos of <br />sale). <br />_1. xs owner ofthe p()peny, am exclusivcly conlractirrg wilh liccilsed conlrachr\ lo conslrucl thc preject (Sec. 70114, Businers <br />and Pn)l;ssinCoderTheContract()r'sLiccnsel-awdoesnotapplytoanowncrofpropcnywhohuildsr)rin)proveslher.oil. <br />and who conlrilqs for such proiccts wirh a Contrack)r(s) liccnscd pursumt to thc C)ntaaclor's Licensc Law). <br />_l ilnr exempt under B & P.C li)r lhir rer\on. <br />W()llKl,lRS'( ()Nll'llNS^ l I()N <br />I)t.t( l_\R\,ft()N <br />I hcr(.hy rllirm un(lcr p.nxhy of pcrjury onc of thc ti)ll()wing dcclaralions: <br />_lhave andwill maintainaCc(itiuateofConsenthSelf-ln$ureforworkers'compensation,as providedforhySecrionST00ofrhe <br />Latx)r Codc, for rhe pcrformrcc ol thc work for which rle pcrmir i\ irsucd. <br />_I have and will maintain workers conlpansali()n insurancc, as required by Secliotr 3T0O ot lhc tjbor Codc, f()r thc perfomree of <br />thc work li)r wlich this pcrmit is issucd. My workcrs' compcnsation insuruncc cafiicr &nd Frlicy numbcr arc: <br />andi-. <br />Policy Nunrbefl Expires: <br />_l ccnity that in the lrcrfornuncc of lhc work for which lhis pcrmil is issucd, I shlll not cnrploy any frcrson in any nlanncr <br />$ as to bccorrc subjccl to lhc workcrs' coilrpensat ion laws of Calilomia, and agrcc lhnt if I slnuld trcorrc sub.iecl to the <br />woAers' compensalion provisions of Seclion 1700 of lhc Labor Code, I shall, fonhwilh $mply with thos provisions. <br />WARNINC: Failure t) scurc workcrs'compcnsation covcrogc Ls unlawful, and shall subjccl an empl()yer rc riminal pmltie md <br />civil lines up lo one hundred thousund dollnrs (Sl(Xl.(Xm). in addition lo thc cosl ofconrpensalion, damg.s as providcd for thc <br />Seclion J076 ofthe Lak)r Cbde, irilerest and att)mey's fees. <br />LICEN)-EDCoNTRAC-T(rR <br />DECLARATION <br />I hcrchy allirm undcr p.nally of p€rjury that I arn licensld under provision oI Chiptcr 9 (commncing wirh Sedion 7ffn) oI I)ivision 3 <br />of lhc Busincss and Prufcssions Codc. ml my licensc is in full f(ire atul cffcct. <br />Liccnsc Class _Liccnic Nurnhcr: _ <br />CONSTR(JCTION I,ENI)ING AGI]NCY <br />I heruhy xllirm under lEMlty of neriury thut there is a constructiotr lctrdilrB ogency f& the performance of the work firr which this permit is <br />issucd (Scc. :1(197, Ci\. C.). <br />l.cnd(r's Nnrne: <br />I-cn(lcr's A(lLlrcs\: <br />APPLICANT DECLARATION <br />I tErcby afiimrundcr penalty of per]rry one ofthe following dcclaratiotrs: <br />DenDlition Pern)ils-Asbcstos Notification Federal ReSulaliotrs (Title.l0. Pan6) <br />-Rcquired <br />lrtter of Notification <br />I cerrily lhxl tlrc Icderal rcgulations reSiuditrI rsheslos rcnx)\'rl rre n({ ilIpli.rblc k) rhis pi)icct. <br />_l ccnify thal I hiive rqrd thi\ applicalion Nxl slale thal the above infornulion is corccl. I ngr@ to comply with all City and County <br />(,rdilunccs and Statc Laws rchtiDg rc buildiilg construdi()r! iuil hcreby autk)rize rcprcseiltatives of this City and County to entcr uF)n lhe <br />atx)vc nrcnti()ncd p()pcf,y fbr inspecli()n puryDses. <br />Appli(unt or AScnt Signfllurc: <br />['rrnril( nanrr <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVl nsulation ;.dl4t)(- C"*ck .zq <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />[Vlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputv Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />FINAL k*?/L €t'1 )/q./c= Z z <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />Bev.08-07-2015