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BUILD!NG. INSPECTOR RECORD <br />Rev.08-07-2015 <br />SITE.WORK DATE ID/SIG.COMMENTS ()wNItR IL)ll,l)ER l)UI-CARATI()N <br />I hcreby affirnl under fEnalty of perjury that I am cxcnrpl from the Cbnlraalo6' License I:w for the following rcason (Sec.7031.5 <br />tlusiness and Prolcssion Codc): Any Cily or Countv which rcquires a ltrrnil lo con\trucl. atlcr, irnprovc. dem)lish or rcpair any <br />slnrcture.priorroirs i-rsuance.rlsorequirestheapplicentt()rsuchpermit()tileasignedstatemcnl thatlEorsheislirenscd pursuant <br />to the pmvisions ol-th(' Contracbr's l.iccnscd liw (Chapter 9. Comnrcncing with Scclion 7(XXl of l)iviNion J ol-thc Busincss and <br />Proles\iorsCodelorthatheorshcisexempttherefromandthebasisfirrtheallegedexenrption. Anyviolati(trlofSeclion703l.5byaily <br />rpplicxtrr for il pennir sub.jccls the applicrnl to n civil perrrlty of not more than llve hundred dolhrs ($5{x)). <br />_1, as owncr ol'tlE prcltny. or my cmployces with wages as lhcir solc compcnsation, will do (hc work and the slructurc is mt <br />iiledcd or offered for mle (Sc.7044. Busincss 0nd Prcfessions C(xle: Thc Contracbr's Liccn* Law docs not apply lo Bn owncr of <br />theprrpcfly wlDhuildsorimprowsthe[rtrandwhodoessuchworkhinNclforhcrselIorthroughhisorhcrowilemployecs, <br />providcd rhal such improvcmnts trc not intcndcd or ollcred lbr salc. Il. howevc( thc building or inprovcmnt is sld within one )ca <br />ofconrplerk[ the Owner Builbr will luvc lhe buftlen of prcving tlut lE or shc dirl m buikl or impn)ve thc profEny for llt Iruqnr of <br />sh). <br />_1, as owner ofthe properly. an exclusively contrrcting with licensed conlraclors to conslrucl tlE pmjecl (Sec. 7O'14, Business <br />ail.l Pn)fessbn Code: Thc Cotrtncrcr'r l,icense Law does not apply k) an owner ofprolE(y who builds or improves thercon. <br />and who contracts for such p(+cts with a Contrackr(s) liccn$d pur\uMl to lhc (bilractor's Liccosc [2w). <br />-lan|etenllnunderSecIit)n-'B'&P,C,ti)rthisreasou,Dale:- <br />woRKEks' coM PUNsA'tr0N <br />DESIABAIIAN <br />I hcrcby alfirm under pcnalty of pcrjury one ofthe following declararions: <br />_lhaveardwillnraintainaCenilicatcofConscnrtoSelf:lnsureforworkers'compersation,as pnrvidcdforbySection3T00ofthe <br />LatDr Cflle. for rhc pcrformrce of rhc work lbr which rhc pcrmil i\ issued. <br />Mhovrrnlwill^aintairworkers compcnsationinsuranc€,as r€quircdbyscction3?00oftheLaborCode,forthctErf(,mh-cofr rhc w(,rk k,r which this pcrmit ls rssural. My workets' comlEnsati()n insurancc cfrier afll lnlty number uc: <br />Policy a <br />_l cc(ily rhat in thc l--rfbrnuncc of rhc work for which rhis pcrnil is issucd, I shll not cnlploy any pcrson in any nunncr <br />so as to tEconE subjcct lo thc workcrs'coilrpcnsation laws olCalilbrnia. dnd sgrcc lhnl il l should becorrc subjcct to the <br />workers' conrpensatioD provisions ofS.clion 3700 ofthe l-abor Code, I shall, fonhwith comply wilh thos prcvisions. <br />WARNING: Failurc to sccure workers'comlNnsation covcrugc ir unlawful. und shall subFcl an cmploycr to triminal Fnalties ud <br />civil fines up to one hundred thousand dollxrs (Slfi).UxD. in nddiliotr to lhe cost ofcomp€nsation. darmgcs ns provided for thc <br />Section lO76 ofrhe titx,r Cule, interest and attomy's fee\.a <br />u,,,..' z/ ), / z-o <br />I)E('I,,\ RATI()N <br />I hcrcby al lirm undcr p€nalty ol perjury rhal I am Iiccn$d undcr pro!ision ol Chnplcr 9 (cornmencinE with Section 70fi)) ol Dilasion 3 <br />of IIN llusincss and Profcssi(lns Codc. md n)y liccnsc is in full fi)rcc md cffccl. <br />[,iccore ,NurnMr:D f/ <br />, <br />CONSTRTJCTION I,ENI)ING AGHNCY <br />I heBhy aflirnr undcr lEilalty of perjury thal thcre is a con\trudioo lendinS agerey ,i)r lhc pcrformrrce ofthe work lbr which this Jxmrit is <br />issucd (Soc. :109?, Civ. C.). <br />lindcr's Nanrc: <br />APPLICANT DECI,ARATION <br />I hercby affmrunder penalty of perjury onc of the following declardtions: <br />DenDlilioD Pernrits-Asbestos Notification Federal ReSulrtions (Title 40, Pnn6) <br />-Requircd <br />trtt('r of Notrficalion <br />I cerlili that rhe fcderal reAuhtions rcgudinS asbesbs rcnx,vill are not flpplicilble kr this projct. <br />lNp eenity that I havc rcrd rhi\ applicalion and st^le lh.l the abovc information is concct. I agre lo comply with all Ciry and County <br />I ordiunces and State llws reltilir)g lo bu ilding construd ion. arxj hereby aullDrize represerilatives of this City and County lo enter uF)n the <br />rlx)!c mcnli()ncd prof-r1y lin' inspcclion purlx)scs. <br />Applicut or Agcnt <br />I'(nriler nanre <br />rhrc ' =/rt/ zo_______7___7- <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVl nsu lation tt ,\,K> <br />Roof Sheathing +//ff,uru Afttrool ^tDShear Wall <br />Framing <br />lnsulation/Eneroy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />lMasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif. <br />I I ,l //r <br />F!NAL 7h6Wtu Abtfo,(Y.-{Y <br />Certificate of Occupancy t I <br />Notes, Remarks, Etc. <br />--> <br />l)rlr <br />[r'n,ler's Addrcss: _