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BUILDING. INSPECTOR RECORD <br />Rev,0B-07-2015 <br />SITE-WORK DATE ID/SIG.COMMENTS OWNI]R BT'II,D1:R I)1:I,CARA'TION <br />IherebyrffirnrunderpetraltyofpcriurythalImrexcmptf@mtheContractoN LicenseLawforth.followinSreason(Sec.7031.5 <br />llusinc\s rnd Prolcssion Codc): Any Cily or Counlv which requircs a fErmil to conslrucl, altcr. improve. dcmolish or rcpair any <br />structure.priort)its issuance.lLsorcquirestheapplicanllorsuchlEmitbfilcasiSnedslalcnEnl lluthcorsheisliccnsd pursuant <br />h lhc pmvisions of Ihc Contraclor's l-iccnsed [,aw (Chaptcr 9. Cornrncncing with Scction 7fi)0 o[ Division 3 of thc Business and <br />Piotls$i('nsCodc)orrharheorshciscxenrpllherefronrandllEbasistorthcallegedexenrprion. AnyviolalionofSectionT03l.5byany <br />npplicnnl for a pcrmit suh.iecrs the xpplicint ro a civil pemlry of not more thn[ five hundred dollilrs ($-5{)0). <br />_1. as owncr ol lhc pro[r(y. or rny employccs with waScs as lheir s)lc comFrcnsalion. will do lhc work and tha stMlurc i$ mt <br />intcnded oroffercdforsalc(Se.T044,Busin.ssandPmfessionsCoderThcConlraclor'sLicenscLawdocsnolapplytoanownerof <br />the prcpcf,y wlb huilds or improves lhdrcn. ud wlx) does such work himself or lrcrself or lhrough his or hcr own cmployees. <br />proridcd rhar such impmvcrrnts ee mt iNcrded orollcrcd for Mle. ll. howcvc{, rtE tililding or improvemnt is $H within one }cr <br />ofcompleli(nl lhe Owrrcr Builder will luvc the burden ofprovinS llut hc or shc did mn build or improvc thc pmpeny for lhe purposof <br />sale). <br />_1, as owner oflhe propeily, am cxclusively con(racting wilh licensed conlrack)rs lo coilslruct the pmject (Sec. 7044. Business <br />ard Pnrllssbn Corle: Thc Contracl()r's License Law d(Es trot rpply lo an owiler oI propeny who builds or improvcs thercon. <br />and who contracts for such proiccts with a Contrack)(s) liccn$d pursumt lo rhc Coilracktr's Licensc llw). <br />-IanreIemplundcrsection-.B,&P'c,lbrlhisrcsson,A.----. <br />WORKI:lLS' COMPI.INSATION <br />DECLARATION <br />I hcrcby allirm undcr penalty ofperjuryonc ofthc lbllowing declaralions: <br />_lhavcardwillnEintainaCcnificatcofCorenttoSelf-lnsurcforworkers'comFnsation,as prcvidcdforbySectionJT00ofth. <br />Lahor Code, for thc perforronce ofthe work lbr which thc pcrmit is issued. <br />_l havc and will maintain workcr' conrpcnsalion insurance, as rcquircd by Scction 3700 of the [:bor Codc, for lhc lErfotlrwc of <br />thc work for which this pcrmil is issucd- My workers' compeosation insurmcc cariff ud plicy numbcr ue: <br />Policy Numb€r: Erpircs: <br />_l cenify thal in thc pcrlormancc of tlre work for which this pcrmil is issucd. I shall not employ uny pcrson in uny manner <br />$ as lo bclsm suh.jcct lo thc workcrs' compcnstion laws of Califomia. and agrce that if I stnuld becom subjecl to thc <br />workcrs'compcnsationprovisionsofSection3T00of(heLaborCode,Ishall,fonhwith$mplywiththosprcvisions. <br />WARNING: Failurc tr sccure worken'compensation covcngc is unlawfill. and shall subject an cmployer to oiminal penaltis and <br />civil fincs up toone hundrcd thousand dollars ($l00,UX)). in addition lo lhc cost ofconrpcn$tion. dam8cs as providcd for lhc <br />Scction 1076 of the Lltbr Cele, intcrest and sllorcy s fees. <br />Ilclc:_ ApDli@nl, <br />I,ICENSED CoT{TRACTOR <br />DT]CLARATION <br />I hcrcby allirm undcr pcnally of perjury tha( I am liccn*d undcr provision ol Chaplcr 9 (comrcncing with Secthn 7ff)0) ol Division l <br />of the Business and Profcssions Codc, affl my liccnsc is in full tbrcc ind eutct. <br />l,iccnsc Class:-l,iccnsc Numhcr: <br />CONSTRUCTION I,I:NDING AGI]NCY <br />I herehy aftirm under lEnulty of perjury that there is a constnrctkxr lenrling agerrey for the Jxrforurce of lhe work for which this lEmil is <br />issued (scc. 3097, Civ. C.). <br />[4nd('r's Nrmc' <br />a <br />APPLICANT DE(:LARATION <br />I her€by affm under p€nally of perjury one of the followinB d{ldationsl <br />Dcnblirion Pernrits-Albestos Notification Federal Regulations (Title.l0, Pan6) <br />-Rcquired <br />ktt.r of Notifi.ation <br />_l ccrtify lhal the federal rcgulatiotrs reg[ding ilsheslos renroval ure not alplicable t) this p()icct. <br />_l cenify thnt I havc rcad this application iud statc thal the above infornralkrn is corect. I agre lo comply with all Cily and County <br />ordinances aild State Laws relating r) buildiuS construction, drl h€reby suthorize reprcscnlalives of this City and County to enler ulrn the <br />atxrve mntioncd propeny li)r inspeclt)n purF)ss. <br />Applicunl or Ag(nt Dater- <br />Prmlle. mme (Drlnt): <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVl nsu lation <br />Roof Sheathing 5 zdzo Dffi)A1 #* <br />Shear Wall <br />Framinq <br />lnsulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />lvlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />I <br />FINAL (t 7,lu Wo A,J 4n <br />Certificate of Occupancy -l \r <br />Note.s, Remarks, Etc. <br />I PW <br />I <br />tn//rn - <br />Carier: <br />l)ete:- Conlrrclor: <br />knder's Addrcss: