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BUILDING- INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG COMMENTS OVYNER BUILDER DELCARATION tI hcreby affirnr undcr penalty of frcrjury that I am cxempt from the Contractors' License l-aw for thc following rcason (Scc.7031.5 <br />Busincss arrl Profcssion Code): Any City or County which requires a prmit to construct, altcr. improve. dcmolish or rcpair any <br />structurc, prior lo its issuance, also requircs thc applicant for such pcrmit to lilc a signed statcnrent that hc or shc is licenscd pursuanl <br />to thc provisrons of thc Contractor's Licensed I-:w (Chaptcr 9. Commcncing with Section 7000 of Division 3 of the Busincss and <br />Professions Codc) or that hc or she is exempt thercfrom and thc basis for thc allcgcd cxcrrtption. Any violation of Section 703 I .5 by any <br />applicant for a permit subjccts the applicant to a civil pcnalty of not more than five hundrcd dollars ($500). <br />_1. as owre*r of the propcrty. or my cmployecs with wagcs as thcir solc compcnsalion. willdo lhc work and thc structunc is rnt <br />intcndcd or oft'ercd for salc (Scc.7044, Busincss and Pnlfcssions Code: 'l'he Contractor's Liccnse [:w does not apply to an owncr of <br />thc propcrty who builds or irnprovcs thercrrn. arxl who does such work hinrsclf or hcrsclf or through his or hcr own cmpkryecs. <br />providcd thnt such inrprovcrncnls arc not irrlcndctl oroffcrcxl for salc. If. howcvcr. thc buikling or irrqrrovcnrcnt is sold within onc ycar <br />of comphtion. the Owncr Buildcr will have thc burdcn of proving that hc or shc did nol buikl or improvc tlrc prof,crty for thc purJnsc of <br />salc). <br />-1. <br />as owncr of thc prcpcrty. am exclusivcly contracting with liccnsed contractors lo conslruct the projcrct (Scc. 7U4. Busittcss <br />and holbssirn Codc: Thc Contractor's Liccnse Law docs not apply to an owner of proJrcrty who builds or improves thcreon. <br />antl who contracts for such projccts with a Contraclor(s) licensed pursuant to thc Conlractor's Liccnsc Law). <br />_l am cxetnpt undcr Scction_, B. & P.C. for this rcason. <br />I)nte:Owner:_ <br />WORKERS' COMPENSATION <br />DF'CLARA'I'ION <br />I hcreby affirrn undcr pcnalty of rlcrjury onc of thc following declarations: <br />_l have and will maintain a Ccrtificate of Conscnt to Self-lnsure for workcrs' conqrensation. as povided for by Scction 3700 of thc <br />Labor C-ode, for thc performance of thc work for which the pcrmit ls issued. <br />4 havc and will rnaintain workcrs' compcnsation insurancc. as rcquircd by Sectiott 3700 of thc krbor Code. for thc perfornuncc of' <br />work lbr which this prmit is issucd. My workcrs' compcnsation insurancc carricr and plicy nunrbcr are: <br />e-J--* e- f ut,^l <br />poricyNurt*r, 42 C7 -l 3'? Expires: 1 f u-ho>l <br />_l ccrrify that in the Jrcrformance of thc work for which this pcrmit is issucd. I shall not employ any pcrson in any rnnncr <br />so as to bccorrrc subjcct to thc workcrs' compensation laws of Calilbrnia. and agrce that if I should bcconrc subject to thc <br />workcrs' compcnsation provisions of Section 3700 of the Labor Code. I shall. forthwith comply with those provisions. <br />WARNING: I.hilurc to sccure workcrs'compensation coveragc is unlawful. and shall subject an cmployer to criminal pcnaltics and <br />civil fincs up to onc hundred thousand dollars ($100,000), in addition to <br />Scction 3076 of thc Labor C-ode, intercst ard atlorrrcy's fecs. <br />cost of compcnsation, damages as provided for thc <br />Applicanl:tvL/, <br />LICENSED CONTRACTOR <br />DTCI-ARATION <br />I am licenscd undcr provision of Chaplcr 9 (comnrcncing with Sc.ction 7Un) of Division 3 <br />my licensc is in full force and cffcrt. <br />I hcreby affirm undcr pcnalty of pcrjury that <br />of thc Busincss and Professions Code. ard <br />License <br />Date: <br />Nurttbcr: <br />to /t t 1>.o tz/ <br />W <br />I hcrcby aflirm urder Fnalry of pcrjury thal theE is I @nstruction lcnding agercy for thc perforMc of the work for which this ]Emit is <br />issued (Scc. 3G)7. Civ. C.). <br />[.cnder's Namc: <br />Lrnclcr's Addrcss: <br />ATEIJCANI.DECI.AMTON <br />I hqEby.mmundcr Fnolty of ]rcrjury onc of thc following dccloolions: <br />Dcmlithn Pcrmits-Asbcstos Notification Fcderal Rcguldions (Titlc 40, P8rt6) <br />-Rcquircd <br />Lrttcr of Notifrcation <br />-l <br />ccnify thlt thc fcdcnl rcgulations rcgarding asbcstos rcmvrlilc mt upplicable to this prcirt. <br />Il:l cedify thot I havc rcad this applbation dd stalc thst thc abovc informlion is coRrl. I agrc lo cort{,ly wirh 8ll City 8nd County <br />o-rdinan@s ard Statc trws rclaling lo building conshrctiorl ard h€reby aulhorirc rcIrcsntatircs of lhis City and County lo ents ulnn thc <br />atxrvc rncntioncd proprty ltlr <br />I'ernritec nanre <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf Ioor/VenUl ns u Iatio n <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />[\ilasonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif . <br />I , l-Ot <br />FINAL It lq\1?IrlY LY1 I <br />Certificate of Occupancy I <br />Notes, Remarks, Etc <br />Rev. 08-07-201 5 <br />Ort", <br />Applicant