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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATTON <br />I hcrcby ulllm undcr JEnalty of pcrjury rhat I am cxcmpl from lhc ContrachN' Licenrc Law for thc tirlowitrg rcasrn (SN.?031.5 <br />lJusincss arl Profcsskrn Codc): ADy City or County whrch rcqutcs a farmil lo c(tnslrucl. alts. improvc. &molish or rcIBir any <br />structurc, lrirr k, it$ issuancc, also requircs thc ,pplicnnt ti)r such [Ermit lo filc a sigrcd statcnEnt thal hc or shc is liccD*d Pursuilt <br />to thc [n)visiot$ of thc Controckrr's Liccnscd hw (Chaptcr 9, Commcncing with Sccti(rn 7000 of Division 3 of thc Busircss and <br />l,rotbssi(rns G)dc) or that hc or shc $ cxcmpt lhcrcli(rm and the bosis lor lhc allcgcd crcmFion. Any vi(ration of Sccliotr 70-l1.5 by any <br />applicant tbr a JErmit suhjccts thc applicant k, a civil pcnalty of n(rt more than fivc hundrcd dollus ($500). <br />_1. as owncr of thc propcrly. or my employccs with wagcs as thcir solc compcnsation. will do thc work and thc strudurc is nol <br />intcndcd or oll'crcd lirr salc (Scc.7(t44, Busincss and Pnrlbssions Crxlc: Thc Conlracl()r's Liccnsc Law docs not apply to an owncr of <br />thc pn)pcrty wh<l buikls ()r improvcs thcrcrrn, aml wlxr drrcs such wrlrk himsclf rtr hcrsclf ttr thrtlugh his ttr hcr own employccs, <br />providcd tlrat such improvcrncnts arc not itrtcndcd or oll'crcd lirr salc. Il. howcvcr. thc buildiltg or imprrvcmcnt is sold within onc ycar <br />ot'complction, thc Owner Buildcr will havc thc burdcn of proving that hc or shc did mrt buikl or improvc the proJrcrty for thc purJxlse ol' <br />sah). <br />_1, asowncr<lt'thc propcrty, amc.xclusivelycontracting with liccnscd conlractorstoconstruct thc pnr.icct (Scc. 7044, Business <br />and lhrlbssion Codc: Thc Contractor's Liccnsc [-aw docs not apply to an owncr of proJrcrty whrl builds ttr inrprtlvcs thcrcon. <br />and who contracls klr such pnl.iccts with a Contractor(s) liccnscd pursuant to thc Conlraclor's Liccnsc Law). <br />-IanrcxcmptuttdcrScclitltt-'B'&P.C'lilrthisrcasrln.I)itlc: <br />WORKEIIS' COTTT PENSATION <br />DECLARATION <br />I hcrcby al'l'irm undcr pcnalty ol'prjury onc ot'thc lirlkrwing dcclaratittns: <br />_l havc and wili maintain a Certillcatc of Conscnt to Sclt-lnsurc tor workcrs' comJrcnsation, as pnlvidcrl for hy Scctitln 37ffi rtf thc <br />Latxrr Ctxlc, tirr thc pcrtormancc o[ thc work lor which thc Jrcrmit ls issucd. <br />,K""and will mainrain workcrs' comFrcnsation insurancc, as hy Scction l7([ of thc Lahor Codc, lor thc pcrtitrmancc rtf <br />thc wrlrk Ie.^rtnit My irrsurarrcc camicr and Jxrlicy rtumhcr arc: <br />L <br />Pulicy -- <br />_l ccrtrly that rn thc Jrcrlirrmancc o[thc work filr which this Jrcrmit is issucr], I shall nol cmploy any Pcrson in any manncr <br />so as to bccomc suhjcct to the workcrs'comJrcnsation laws of Calililrnia, antl agrcc that if I shtluld bccome subject to thc t <br />workcrs' comJrcnsation provisions of Scction .17fi) of thc Lahlr Crxlc, I shall. t'orthwith comply with tfxlsc provisions. <br />WARNING: Failure to rccure workers'comJrcnsation covcragc is unlawtirl, and shall suhjcct an cmpktycr to criminal pcnalties and <br />civil lrncs up hundrcd thousand dollars ($1ffi,fiX)), in to thc of comJrcnsation, damagcs as providcd for thc <br />Scction -1076 thc CrxJc, intcrcsl anrl attorncy's t'ccs. <br />t0 <br />I hcrc'hy allirnr undcr pnalty of pcr.iury that I am liccnscd 9 (commcncing with Scclkrn 7U)()) of Division -] <br />of thc llusincss and Pnrl'cssions Code, and my liccnsc is in l'ull lilrcc atil cl'tbcl. <br />Liccnsc Class:c ?o zE <br />(]0NSTRI.J(II'ION I.T,N DI N( ;,\( ; F]N (]}' <br />I hcrcby atlirm undcr JrcMlty of perjury thtt thcrc is a (urstructknr lcnding agcncy for the Jrcrtbrmncc ()f thc work for which this Frmit is <br />issued (Scc. 3097, Civ. C.). <br />kndcr's Namc: <br />lrndcr's Addrcss: <br />APPLICANT DECLARATION <br />I trcrchy allirm undcr pcnalty of pcrjury onc of thc lollowing rlcclaratiotts: <br />Demolitiorr Pcrrnits-Asbcstos Notification Fcderal Rcgulations (Titlc 40, Pan6) <br />-Requircd <br />l-cttcr of Notilicatkrn <br />._l ccrtily that thc fcrlcral regulations rcgarding asbcslos rcmoval arc not apphcablc to this projcct. <br />_l ccrtity lhat I havc rcad this applicaturn utd statc that inlornration is corrcct. I agrcc to contply with all City and Coullty <br />ordinanccs and State Laws rclating to <br />ahovc mcntioncd propcrty lirr <br />Applicarrt or Agent <br />Penrrilee nanre <br />hcrcby authorizc rcpresental ivcs of ')J"'r)ru"'"""^"'* <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenUl nsu Iatio n <br />Roof Sheathing <br />Shear Wall <br />Framinq <br />lnsu lation/Energy <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 />Engineer Fina! Report <br />Flood Zone Certif. <br />,t .t Dr <br />FINAL '0 lz,l"lW Dftfrft I <br />Certificate of Occupancv <br />Notes, Remarks, Etc. <br />Elorr nQ-n7 3n 1 q