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BUILD!NG. !NSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS owNt:R Irtiil,t)t:R t)t:t,cARATtoN <br />I hcreby affrm unde. penalty of perjury that I am excnrpt fronr the ContracloE' License lrw for the followint rcasn (Scc.7031.5 <br />llusincss aM Prol_ession Codc): Any City or Counlv which rcquires a fErmit to conslruct. alter, improvc. demrish or rcpair any <br />slructure. prior to its issuance. also rcquircs lh€ applicanl lbr such pemil to file a signed slalcrcnl lhat lE or slrc is licetrEd pursant <br />to thc pmvisions of thc Conlrrclor's l,icenscd lnw (Ch0ptcr 9. Comrncncing with Section 7000 ol l)ivision 3 o, thc Busincss and <br />Prote$si(ms Code) or thal hc or she is excmpt therefiom and tlE basis tbr the alleged exenrpliotr. Any violarioil of Secrio 703 I .5 hy ,ny <br />applicrnl for a p€mit subjects the npplicailt lo n civil pcnnlty of not rmrc th{n five hundrcd dollars ($5(X)). <br />_1. as owncr ol rhc propcnv, or my cmployccs with wagcs as thcir solc compn$tion, willdo (hc work ard the stmrure ir mt <br />irilcnded or offered for sle (Se.7(X.1, Business and Prefcrsions C(xle: The Contractor's Licensc law docs not opply to an owncr of <br />thcpn)pely wk)buildsorinproveslhersiLUrdwlk)doessuchworkhimselforlErselforlhroughhisorherowncmployees. <br />providcd tha( such improverrcnts ue ml intcndcd or ollbrcd lbr srlc- ll, howcvcr, rhc buiHing or improveimnt is yrld wihin onc )ru <br />ofconpbtiu, the Owner Buildcr will luve the burdel ofpovirg lhd lt or she clid N{ build or improve lhc prcpcny [)r tlE puq$se of <br />srlc). <br />_1. rs owner ofthe propefly, am cxclusivcly conlracting with licensed conlrtclors lo conslruct the preject {Sec. 7{X4. Business <br />and [\)lesstilrCode:TheCrxtractor'sLicersel,awdoesnotupplykranownerofpropertywhobuildsorinrprr)vcsthereoil. <br />nnd who con(racls for such pro.iccts wilh a Contracktr(s) liccnscd pur\umt lo lhc Contractor's Liccnse LAw). <br />_l am excmDt under Section-, B. & P.C. t()r this reasoD. <br />w()RKt :RS' ('Ol\tPIINSA'IION <br />IX]CI-ARATI()N <br />lhcr!'hynllirmundcrpcnaltv(,fpcrjuryonc(,llhcli)tl()wing(lc(hrilttr'ns: <br />_lhrvearxlwill nEintainaCenilicntcofComentk)Selflnsureforworkers'conrpe[salion,as pmvidedforbySection3T00oflhe <br />Latnr Codc, {or the lrcrformmc of thc work ,br which |hc pcrmil is issucd. <br />_l have and will nraintain worken'conlpcnsati([ insurancc, as rcquted by Section 3700 ofthc tjhor Code, tir thc pcrfomutre of <br />thc work lbr which this pcrmit is issuql. My workcrs' crmlEnsation insurilncc cMicr luxl lDlicy numtrr ilc: <br />Policy NumtEfl Expircs: _ <br />_l ccrity that in the 1*-rfornuncc ol tlrc work li,r which this pcrmil is issucd, I shlll not enrploy any pcrson in any ntanncr <br />so as to bccorrc suhject to the wo*crs' coillpcnsal ion laws ol Cnli lornia. xnd agrcc that if I should bccorrc suhjccl 1o I hc <br />worlers'compensationprovisionsofSectionlT00oftheLat$rCbde,Ishall,fofthwithcomplywithtlDsprovisioils. <br />WARNING: Failure to sccure workers'compcnsrtion covcrirgc ir unlawful, dnd shall subjcct an cmploycr b criminnl pcnahic$ and <br />civil liDes up to one huDdred thousatrd dollrrs ($l(X).(XX)). in odditiotr to the cosl olcompensalion. damages as provided for the <br />Sectiotr 1076 of the tibor Cixlc, interest and atbrncy s fccs. <br />I,I(:ENSRD CONTRA(:ToR <br />!l!:l@IJgN <br />I hcrcby allirm under f*naltyol pcrjury thal I arn liccnsd undcr provision ol Chnplcr 9 (cornrrcncing with Scctirn 7(XX)) ol J)ivision :l <br />of rhc Business and Prcfcssions Codc. ill n)v liccnsc is in full Iarcc md cffcct. <br />Liceosc Class:-Liccnsc Numbcr: <br />(-.rnlroclor <br />CONSTRTJCTTON I,1;NI)ING AGENCY <br />issucrl (Scc. 1097, Civ. C.). <br />I rn(lcr's N^mcr <br />lrn,lcr's Address: <br />APPI,ICANT DECI,ARATION <br />I hercby affm under penalty of pcrjury one of the followiDg declarations: <br />DenFlition Permils-Asbestos Notificarion Federill Regulntion$ (Title.l0. Pdn6) <br />_Required trtter of NotificalioD <br />_l cenily thar rhc federal rcgulations rcgarding astEsbs rcnDval arc not applicablc ro this prcjdt. <br />_l cc(ify thal I luvc rad lhis application anl statc that lhc abovc infomtion is corect. I agrE to crmply with all Cily and Counly <br />odiunces and Statc liws rclatiDs to building constructioD. arxl h.rchy autlDrizc rcprcsntativcs ofthis Ci(y ail County to cnt6 uFDn thc <br />ak>vc arcntioned prcpeny for irupedion purF)ss. <br />Applicrnt or Agcnt <br />Pemlle tlMG (prlnt): <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 <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />[t/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />FINAL 7.%-ua > Jdlsfi ?c@) <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />Rev. 08-07-201 5