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BUILEING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hercby ailirm undcr FDally of Frjury lhal I am cxcmpt fiom thc Conlrackrrs' Lrccr$c Law firr thc folktwing rcasrn (Scc.7)-11.5 <br />BusiDcss ail Prolbssi(rn C(xlc): Any City or County which rcquircs a lErmit to construct. allcr. improvc. dcmrlish or rcpair any <br />structurc, pri)r b its issuancc, also rcquires thc applicant for such lErmit to lilc a siSncd statcmnl lhat hc or shc is liccnsd pusuant <br />k) thc provrsiurs ()f lhc c(rntractor's Liccnscd llw (Chaptcr 9, Commcncing wilh SR-lion 7000 r,f Division .l of thc Busincss and <br />Ptulcssions Codc) or that hc or shc is cxcmpt thcrcliom !trd thc basis for thc allcgcd cxcmltion. Any viol.lion of Sethn 701 1.5 by any <br />applic0nt tbr a pcrmit subjccts thc 0pplicalt lo a civil pcnalty of Dot m)rc lhatr five hundrcd dollus (.$5fi)). <br />_1. as owncr ot'thc propcrty. or my cmployces with wagcs as thcir solc compcnsation, will do thc work arxJ lhc strtrr*lurc is nol <br />intcndcd or ()ll'crcd firr salc (Scc. 7044, Busincss and Prct'cssions Ctxlc: Thc Contract()r's Liccnsc Law docs not apply lo att owncr of <br />thc pn)pcrty who huilds or itnprovcs lhcrcon. arxl who drrcs such work himsell'or hcrsclf or thfl)ugh his or hcr own cmployccs, <br />providcd that such impnrvcrncnts arc not ilrtexled or ollbrcd ltlr salc. It, howevcr, thc buikling or imprlvcrrcnt is sold within ()nc ycar <br />ol'complction, thc Owncr Buildcr will havc the hurdcn ol'prlving that hc or shc did not build rlr improvc thc pruJrcrty for the purJnsc of <br />salc). <br />_1, as owncr ol'thc pn)perty, am exclusivcly contracting with liccrrsctl conlractors to cottsttuct the pro.icct (Scc. 7044, Busincss <br />and hufcsskrn Codc: Thc Contraclor's l-iccnsc [-aw rkrcs not apply to an owncr of proJrcrty who builds or improves thcreon, <br />and who contracts tirr such projccts with a Contractrlr(s) liccnscd pursuant to thc Contractor's Liccnsc [-aw). <br />-l <br />am cxempt undcr Scction-, B. & P.C. tbr this rcason. <br />ft..r^, <br />WORKERS' COI\IPENSATION <br />DECLARATION <br />I hcrcby alllrm undcr Jrcnalty ol'1^-rjury onc of thc tirllowing dcclarations: <br />_l have arrd will maintain a Ccrtificatc of Conscnt to Scll'-lrrsurc lirr workcrs' comgrcnsation, as pnlvirlcd fbr by Scctitln -i700 of thc <br />l-atxrr Ctxlc, lor thc Jrcrtbrmancc of thc work lirr which thc grcrmit is issucd. <br />_l havc arrd will maintailr workcrs' comJrcnsation insurancc, as rct;uircd by Scct ion -1700 ot'thc Lahor Codc. lirr thc Jrcrlirrmatrcc tlf <br />the work lirr which this Jrcrmit is issucd. My workcrs' comlrcnsation insurancc carricr and Jxllicy nunrhcr arc: <br />Policy <br />_l ccrtity that in thc Jrcrlirrmancc of thc work tirr which this Jrcrmit is issucd, I shall not cmploy any pcrson in any manncr <br />so as lo bcconrc subjcct to thc workcrs' comJrcnsation laws of Calitbrnia. and agrcc lhal if I should bccomc subjcct to thc <br />workcrs' comJrcnsation pnrvisions o[ Scction 3700 of thc Lahlr Crxlc, I shall, lbrthwith comply with thosc pnrvisiotts. <br />WARNTNG: Failurc to liccure workcrs' comgrcnsati()n c()vcragc is unlawl'ul, and shall subjcct an cmploycr t() criminal Jrcnaltics and <br />civil linc-s up to onc hundrcd thousand dollars (Sl00,Un), in additir)n lo the cost o[ comgrcnsatiott, damages as providcd for the <br />Scction 3076 of the latnr C<xlc. intcrcst and atlorncy's l'ccs. <br />LICENSED CONTRACTOR <br />DECLARATION <br />I hcrcby atlirm under Jrcnalty of pcrjury that I am liccn:icd undcr provision of Chaptcr 9 (comnrcncing with Scction 7UX)) of Division -] <br />of thc Busincss and Pnllbsskrns Codc, and my liccnsc is in full tilrcc and cft'cct. <br />Liccnsc Class: Liccnsc Numbcr: <br />W <br />I hcrcby atfum undcr lEnalty of lrcrjury rhat th@ is a construction lcnding agcrey for thc Jrcrfomc of lhc vork tbr which lhis JEmit is <br />issucd (Ss. 3097, Civ. C.). <br />[,cndcr's Name: <br />lrnder's Address: <br />_l ccrtily lhat thc f'cdcralrcgulations rcgurling ashcstos rcmovalarc not applicablc to lhis projcct. <br />_l ccrtily that I havc rcad this applicnti(rn afil statc thal lhc ah)vc irformation is corect. I {!rc to comply with all City and County <br />orditraNcs and State kws rclating k, building construction, .ur, hcrcby auth(rrirc rcltrcscilativcs ofthis City {[d County lo cntq u[[n thc <br />at[vc mtrtioncd JrroJEny for insJEctioD puqr)scs. <br />Applicant or Agent Signaturc: Date:- <br />I'enrrilcc nanre I nrirrl lr <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenUI nsu Iatio n <br />Roof Sheathinq <br />Shear Wall ,uil% n tt^44d '?7) <br />Framinq t I 04 <br />lnsu lation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />[\Iasonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif. <br />/// <br />FINAL t//e6/,u,A z/l <br />Certificate of Occupancy '/f (// <br />Notes, Remarks, Etc. <br />Flnrr <br />APPLICANT DECLARATION <br />I lrcr,-by allirm undcr pnalty ot'Jrcrjury one of the lblklwing rlcclarations: <br />Dcnxrlition Permits-Asbcstos Notification Fedcral Rcgulations ('Iitle 40, Part6) <br />_Rcquircd Lrttcr of Notilication