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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS oIVNER BUII,DER I)EI,('ARATION <br />I hcrcby affi[n uilder penalty ofper-iury lhal I tun exempt fi'on] thc (-onlraclors' Liccnse Larv ftrr the follorving reason (Sec.70.ll-5 <br />Business antl Profssion Code): Any ('ity or ('ounty which rcquiles a pornit lo constnrct. .ltq. irnprove. demolish or rqrair any <br />stnrcturc.puorloits issuance.alsorequireslhcapplicantforsuchpermillofileasignedslatenrcnl lhalheorsheislicensed pursuanl <br />k) thc prorisi(xls ofthe Conlractor's l,iccnsed l-arv (Chaplo 9. (innillencing *ith Section 71100 of l)irision -l ofthe [Jusiness ancl <br />Professions (bde) or lhat he or she is erempl lhfrefion and lhc basis for the alleged exemption. Any violation ofSeclion 70-1 1.5 h! nn! <br />applicant for a pennit subjets the opplicanl lo a civ i I penalty o f not rnore than llve hundred dollils ( $500 ). <br />I. as os ncr of l he pro[Erty. or in] enlpb) e6 s'ith rvagc as their solc conrpensat ior. \'ill do the \t'ork and lhe slructue is not <br />intorcid orofferedforsle(S(.70.14.Busin6saf,dProfdsions(bde:'lhe(inrlraclor'sl.icflscl-a\vdo6nolapplytoanownerof <br />thepNlBly *hobuilcLstrrimprovsthqqu.mdwhodo6suchs'orkhintsclforlterselforthrcughhisorheros'nernplolcs. <br />providecl that such itnprovqnents de n(x inlmdql oroffqed for slle. lf. ho$evq. llre building or ituptolcnrcnt is sold wilhin oile )ear <br />ofcompletion. thc Orvner Builde rvill harc the trurclm ofproving thal hc or she did not hrild or irnprcve thc pKrpdy fu the purfrcseof <br />salc). <br />. , I. as os ner oflhe prapffy. am erchrsivel)- conlraclinS $ ith licensed conlraclors to conslllrct lhe proiccl (S$. 7044. lJusinas <br />and Prcfshn Code: -[he Conlraclor's l.icense l.as'doc not appl! lo an os'nq' of propmy" rvho builds or improves lher$n. <br />and who conlracls for such proj(ls \r ilh a ('ontraclo(s) licosed pulsuanl lo lhe ('onlraclor's l-icense [-as ). <br />I anr excnrl)l under Section . B. & P.(' li)r this rcason <br />Dnte: Owneri <br />\1oRKERS' ('0NtPllNSA l lON <br />DE(]I,ARA'I'ION <br />I hercbr affirrn undcr penalty ofpoju* onc oIthe follorving declaratitmsr <br />_-l hale md $'ill mainlain a Cenillcate of ('onsot to Self-lnsure for $orkcs compensalion. as prolided for by Sslion -r700 of the <br />tabor Code. for the pqfomance of lhe u'ork for Nhich lhe ponit is issued. <br />lhavcandsillnaintaintorkcrs conrpensalioninsurance,as requircdhySection.lT00ofthel.abor(ode.forthepofornlanccof <br />lhe work for rvhich tlris pennit is issued. My w'orkrs'cornpcnsatt)il insilrf,nce carier ancl 1relicy nunttrer a'e: <br />( arricr: <br />I'olicr Nunrhcr:[]xpires: <br />I ccflify that in lhe perfomMncc ofthe *ork for \hich this permt is issucd. I shall not enplo;" any Jrrson in any manner <br />so as to hecomc subjel to lhe workss'cornpcnsrtion la$'s ofcalifornia. and agre thal ifl should becont snhi(l to the <br />wo*trs' cotrtprnslion provisions ofS$(ion 3700 ofthe Labor Code. I shall. foflhsilh conrply Nith lhor provisions. <br />\YARNING: liailure b Kure $orkm'con]pensalion covemge is unlawful. md shall subject an onpk)yer to aiminal potltis lnd <br />civil fincs up k) onc hundrcd thousand rlollars ($100.000). in k) lhc of conrgrcnsalion.as [or lhc <br />Secli(m -1{)76 interst nnd nllorncv s <br />,\pplic{il <br />I hereby aflirrr undo ptrah)'ofperjury lhat I tun <br />of lhe Busin6s and Pnrfasions ('ode. and uv I <br />of('haplq I (cornnrencing rr ith Seclion 7000) of t irision ll <br />ts force and cffcct. <br />License ('lass: <br />Dnle: <br />l.iccnse <br />(-(trll raclor: <br />I horhy aflirnr under ;rcnalty ofpcr.iury lhat lhqe is a lmding agocy for the pqfonnance of the work for rrhich this pmnit is <br />issued (Scc. 11097. ('ir. ('.). <br />Lende s Nanlc: <br />Lcrtlcr's AdrIcss <br />APPI,ICANI' DIi('I,ARAIION <br />I h6eby allinn uilder l)enalty oI pe|jury onc ol thc follo* ing tlcclarat ions: <br />Denrlil i()n Pcrmils-Asbestos Nolifi cation l <br />jedc'ral Regulal ions ( I illc .l0. l'afl (,) <br />Rcq[ir cd Lcltcr of Nolifi cali(nr <br />I cfiify thal the f<leral regulations reguding asbestos ronoval arc nol applicable b lhis preist. <br />I colify lhat I hrve read this appli.ation and slnte lhat the alFvc infornlnt ion is corect. I with all City and ('()unly <br />orclinanccs an<l Sliltc Lil\s relrling lo hrriklin!lhc <br />ntxr\c nrcnliolcd pr()pc,1] [or inspccli(rD <br />,\pplicatrl or Agcnl Sigilalurol <br />Pcrnlilcc il{me <br />ior. an(l <br />l)nl(: <br />anrl 1o crils <br />e <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bfloor/VenUl nsulation <br />Roof Sheathing <br />Shear Wall <br />Framinq <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />FINAL bLg-z.uo JdcJd "@)Certificate of Occupancy <br />Notes, Remarks, Etc. <br />v