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BUILDING. INSPECTOR RECORD
<br />Rev.0B-07-2015
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNITR BUILI)llR l)l),CARATION
<br />I herehy affirnr under penalty of perjury that I mr exempt fiom llE Contractos Licensc ljw for the followirg rcaron (Sec.703 1.5
<br />Busincss and Prolession Codc): Any Cily or County which requircs s Frmit to conslrucl. allcr. improve, deholish or rcfair any
<br />structure. prior b ils issuancc. also requires thc applicrnt lbr such pcmril k) lilc a signed slatcmnl that hc or shc is licensed pursuanl
<br />lo thc nrovisions of lhe Contrdctor's l-icenscd liw (Chapter 9. Comrncncin8 wilh Section 7{Xx) ol l)ivision 3 ol lhc Business and
<br />Protes\tnlsCodc)ortharhdorsheisexempttherefronlandtlEbasistbrllEalleSedexenlpti(nr. AnyviolarbnofSectionT03l.5byary
<br />rpplicilnt for a [Emir subjects the npplicrnt to a civil perrrlty of not nmr. thnn llve hundred dollrrs ($5U)).
<br />_1. as owner oI thc profEny, or rny employccs with wagcs as the ir $lc cornpcnsation, will do thc work and the structue is mt
<br />irlcrrlctl or offered for salc (Sc'.7tX4, Business and Prcfessions Code: Thc Conlrnclor's Lioensc Low does not spply lo an owncr of
<br />theprclEfly wlsbuildsorimprovcslheren,sndwl$dessuchwo*himselforlErselforlhloughhisorherownenlployees,
<br />proyidcd that such improvdrots e mt intcrded orollcrcd for slc. ll. krwcvcr. lh. buildin8 or irprovcmnt is old within one yee
<br />of conrpletinr rh€ Owrcr Builder will have the burden of pmvin8 llw lE or shc did mt build or imprcve lhc pmFMy for rtE purpos of
<br />sld).
<br />_1, rs owrcr ofthe prof,crly, am cxclusively contrrctirlg with licenscd conlraclors 10 conslruct the project (Sec. 7044, Business
<br />atrd Pf,)lessiorCodc:Thc(\)nlractor'sLicensel,awdoesmrtapplyt)ail(,wnerofpropef,ywhohuiklsorimprovesthereon.
<br />and who conlracls for \uch proiccls with a Conlrach(s) licenscd pursuant to thc Contraclor's Liccnsc Law).
<br />_l anr exempt undet Scc(ion_, B. & P.C. tbr this reasn.
<br />woRKIIRS' COt\IPUNSA II()N
<br />I)ECI,ARATI0N
<br />I hcrchy allirm undcr pcnrhy ol'pcrjury onc of thc Ibllowin8 dcclarari(,ns:
<br />_l have a8l will mintain a Cenificale of CoNcnt to Self:lNure for workers' conlpc[salion, as pnrvided for hy Saction J700 of thc
<br />ljtnr Codc, tor the [E formrcc of thc work tor which the permil is i\sucd.
<br />5-!.nuve ona witl maintain workers'comp€nsation insurancc, as rcquired hy Scclion 3700 ofthc l-ahor Codc, for the pcrfomBnce of
<br />lhc wnk I(il s4licll lhis lL'rnrl ir issucd. My wrrkcts' ()nrl)cnsrti()n insurnDcc crnicr anl po[cy nunrbcr iu'c:
<br />Pnli"y Nurrrl*r, U.*prr,*,fl ta)no
<br />_l ccf ily lhat in the lrrti).nuncc of the work for which this pcrmil is Nsucd. I shall not cnrpk)y any pcrson in any manncr
<br />s as lo hccorrc subjcct to lhe woakcrs'conlpcnsatiol laws ofcalifornin, a[d xgrcc that iil should bccotrrc subjcct to thc
<br />workcrs'compeDsationprovisionsofSectionl?00oftheLaborCode,lshilll,lb(hwithcof,)plywithtlDsprovision$.
<br />WARNING: Failurc b sccurc workcrs'compcnsilion covcrdgc is unlawtrl. an(l shall suhjcct an cmployer t) triminal Fnahies md
<br />civil lincs up lo one hundrcd thousand doll{rs ($ltx),lxx)), in ddilion lo lhe cosl ol conrpcnsnlion, damages ax provided for lhe
<br />Secli([ ]076 of the htrr Crxlc, intcrest and atk)rcy s fees.
<br />D,r",712/a o fiori^n,
<br />I,ICENSED CoNTRA(]T0R
<br />I)I'CLARATrcN
<br />I hcrc'hy al liiln undcr l--nalty ol pcrjury that I arn liccn$d undcr provision ol Chnptcr 9 (cornrrcncing with Section 7(XX)) ol I)ivision l
<br />of thc Busincs\ and Profcssions Codc- md nrv liccnsc is in tull lbrcc and cllcct.
<br />l,iccnse *",.*., 86i lO 9
<br />,*,' 3lLl7-o
<br />W
<br />I heBhy aflirm under Fnaly of pcrjury rhat ihere is a construction hrilLrg ageNy for rhe lrrfomrre of the work for which rhis pemil is
<br />issucd (Scc. 3097, Civ. C.).
<br />lJndcr's Nnmc:
<br />[:ndcr's Addrcss:
<br />APPLICANTDECI,ARATTON I
<br />I ffiy affmr under pcnahy of pcrjury onc of thc followint delararions:
<br />Dcmlition Pcrmils-Asbestos Notification Fcdcral RcBularions (Ti(lc 40, Pan6)
<br />_RcquLcd trttcr of Notification
<br />,,
<br />-l
<br />certili that thc fcderalr.gulations rcgdding ashcstos rcmvalare nor epplicable to rlris prriar.
<br />)>al caify rhar I havc rcad rhis applicalion aill slatc that lhc abovc infomlion is corar. I agr@ lo rcmply with all City and County
<br />ordirunccs and State ljws rclaling to building coNtrudio[ arxl hercbyauthorize rcprc*ntativcs of this City md County to cnld upon tlr
<br />atxrr'c mntioned propeny lirr hsprction pur;nscs.
<br />Appli(unt or Agcnt
<br />l'rilrikc natrr(
<br />,r,*, ? /L/70
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsu lation
<br />Rool Sheathinq
<br />Shear Wall
<br />Framinq
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />ltrlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enoineer Final Report
<br />Flood Zone Certif
<br />FINAL W lolLli '/) ,1,.\{l0a*Y
<br />Certificate of Occupancy rl
<br />Notes, Remarks, Etc.
<br />1 ,,./rr I
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