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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNIiR II UII,DER DI.:I,CA RAI'ION
<br />I hereby affirm under penalty of perjury that I am exempt fronr the Contractors' License Law for the following reason (Sec.7031.5
<br />IJusiness and Prolbssion Code): Any City or County which rcquires a Jrerrnit to construct, alter, irnprove. demolish or repair any
<br />structurc, prior to its issuance. also requires the applicant tbr such permit to filc a signed slatemenl that he or she is licenscd pursuant
<br />to thc pmvisions of t}r' Contractor's l.icensed t.aw (Chapter 9. Comrnencing with Section 7000 of Division 3 of the Business and
<br />Professions Code) or that he or she is exempl therefrom and tlrc ba.sis tirr the alleged exenrption. Any violation of Section 7031 .5 by any
<br />applicant for a pxnnit subjects the applicant to a civil penalty of not rxrre than five hundred dollars ($5U11.
<br />&-- owner ol'thc property. or my employees wirh wages as thcir solc compcnsation, willdo the work and the stnrcturc is not
<br />intcrxled or offered for sale (Soc.7(X4, Business and Professions Codc: The Conlraclor's License l-aw docs not apply to an owner of
<br />thc propcrty who builds or improves thereorl and who does such work lrimself or hcrself or through his or her owrt employees,
<br />providcd that such improvenrcnts are rnt intended or olTered for sah. Il. hcrwever, the huilding or irryrrovemnt is soH within one )tar
<br />of conrpletion, the Owner Builder will have the burden of proving tlurt he or she did not build or impnovc the properry for thc purpose of
<br />sah).
<br />_1, as owner of the property, am cxclusively contracting with licensed contractors to conslrucl thc project (Sec. 7044, Business
<br />anl holesskrn Code: The Contractor's License Law does not apply to an owner of property who builds or improves lhercon.
<br />and who conlracls for such projects with a Contractor(s) licenscd pursuant lo the Contractor's Liccnse Law).
<br />_l am excmpt under Section ^ B. & P.C. lbr thisl:ason.;.,J-a5ro ru,
<br />WO R KIiRS' COM PI.:NSATION
<br />DECLARATION
<br />I hcrcby allirm under pcnahy of perjury one of the tbllowing declarations:
<br />_l have and will maintain a Certificate of Consent to Self-lnsurc for workers' comprcnsation, as provided for by Section 3700 of the
<br />I".abor Code. for the performance of ttrc work lor which the permit is issucd.
<br />_l have and will maintain workers' compensation insurance, as required by Scction 3700 of the l-abor Code, for the performance of
<br />the work for which this grcrmit is issucd. My workcrs' compcnsation insurance carrier and pnlicy numher are:
<br />Carrier:
<br />PoIicy Nunrtrcr: Expires:
<br />FY*HH:ilj::lH',",H:tr;l'5#',ffi:Iffil}".:i,"H,I I"T:i*"'HllH,'il',,',:',;:1ff'ffi#,1:lmanner
<br />workers' comJrcnsation provisions of Section 3700 of the Labor Code. I shall, forthwith c'omply wilh thosc provisions.
<br />WARNING: Failure to sccure workers'compensation coverage is unlawful. and shall subject an cmployer to criminal penaltits and
<br />civil fines up to one hundred thousand dollars ($100,UX)), in addition to the cost of compcnsation, damagcs as providcd for the
<br />fees. ^a,(lrn,,;Li 0-l ,
<br />I,ICENSED CONTRA(:TOR
<br />DECLARATION
<br />I hcrcby allirm undcr pcnalty of perjury that I am liccnsed under provision of Chapter 9 (commencing with Sectkrn 7(m) of Division 3
<br />of the Business and Professions Code, and my license is in full tbrcc and etTcct.
<br />License Number:
<br />a
<br />a
<br />CONSTRI.'CTION ],F:NI)ING AGI.]NCY
<br />I hercby all-rnr uruJer penalty of perjury thar rherc is a construcrL, L,r,li,rg 'ug.,*y f'* tl* p.rformance of the work for which this frnrrfis
<br />issuc<t (.Scc. 3097. Civ. C.). o '
<br />Lender's Nanrc:
<br />a
<br />lrnder's Address:,I
<br />APPLICANT DECLARATION
<br />I hcreby affrnr under pnalty of perjury one of the following declarations:
<br />Dcnrclition Permits-Asbestos Notification Federal Regulations (Title 40, Part6)
<br />_Required lrtter of Notification
<br />?
<br />_l certity that the federal regulations regarding asbeslos removal are not applicable to this project.
<br />l}fu [il:ili:;;liJltll',rHT,:l#Lxl#il,l ,::.[f"ffi iT,'].",",xff 1;"1HT:ffi txY
<br />with all City and County
<br />and County to enter upon thc
<br />atxrvc mcntioned propcrty lirr
<br />Applicant or Agcnt
<br />Pernritee nanre
<br />puqx)scs.
<br />Set Backs
<br />Forms/Stee!/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Su bf loor/Ve nVl n su I atio n
<br />Roof Sheathinq
<br />Shear Wall flBlz0 D(1-*"7
<br />Framing vlt<12r9 r>A 4-.5 ,y'
<br />!nsulation/Enerqy I
<br />Dtywall -,/
<br />Lath
<br />Coat
<br />-ld l'ulzt Dr*tf/q/27/za -04**7
<br />Jt/asonrv
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />t n
<br />FINAL \t \\1 0 bAr#'ry\
<br />Certificate of Occupancy
<br />Notgs,,Remarks, Etc.l
<br />5lt,
<br />e//z (-
<br />Rev. 08-07-2015
<br />flntr 7/
<br />lb I Z7o 7) '+u/lr,)v *t
<br />I
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