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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUTLDER DELCARATION <br />I hcrcby affirm undd pcmlty of Jrcrjury thd I am cxcmpt firm thc G,ntrackr6' Liccns Law lbr thc following rcaurn (Se.70J1.5 <br />Busincss ad Profcssion Cu.lc): Atry City or County which rcqutcs a ;rmit kr construcl. altcr. improvc. dcmrish or rclair my <br />slructurc. lrior to its issuoncc. alsb rcquircs the spplicsnt for such Ismit to fih a sigrcd slalcnEnt lhal hc or shc is liccnsd pusuant <br />k) thc [x]visions of lhc Cotrractor's Liccnscd Law (Chaptcr 9, Commcncing with Setion 7fi)0 of Division -l of thc Busincss and <br />Prot-cssiurs Codc) or that he or shc is exempt thcrcliom and the basis for thc allcgcd cxcmption. Aly violotion of Setion 703 1.5 by any <br />applicantraJErmitsubjetslhc applicanttoacivilpcnaltyofn(rtmorclhanfivchundrcddollus($5fi)). <br />Y-'.Kkturrc propcny, or my employccs with wagcs as rhcir slc clmlEnsation, will tlo thc work uxl thc strxlurc is rut <br />inteulcd or ollcrcd firr sah (Sa,7(X4, Busilcss and P(rfcssions Culc: Thc Contractor's l.iccns kw d(xs not alply to an owncr of <br />thc [rr)IErty wtf,, builds or impn ws thc8n\ arrl wlx, d(Es such wlrk himsclf or hcrsclf or thrcugh his or hcr own cmphyccs, <br />pruvidcd that such imlrcwrenls e nrt intculcd or ollbnl ti]r eh. If, hrwcrcr, thc building or imlf,orcrcnl is sld wilhh orc ]r{ <br />otcomplction. lhc Owncr Builhr will haw thc burdcn ofFoving that hc or shc did mt buihl or inqrow thc preJvry for thc pur[{)$ of <br />slc), <br />_1, as owncr of thc pn)lrcrty, am exclusivcly contracting with liccnscd conlraclors lo construct thc pnrjcct (Scc. 7(X4, Busincss <br />and Rrltbsskm Codc: The Contraclor's Liccnse Law docs not apply to an owncr of pro[rcrty who builds or improvcs thercon, <br />and who conlracts lirr such projecls with a Contractur(s) liccnscd pursuant to thc Conlractor's Liccnsc kw). <br />-IamcxcmptundcrScction-'B.&?C.fbrthisreas0n'o^,". Q' tol'zrl <br />"rr <br />DECLARATION <br />I hercby al'lfum under pnalty ol'prjury onc ol'thc lirlkrwing dcclaratiotts: <br />_l havc and will maintain a Ccrtilicatc of Conscnt kl Sclt'-lnsurc lilr wrlrkcrs' compensation, as providetl for hy Scction .17fi) of thc <br />latxrr Culc, lilr thc Jrcrlirrmancc ol'thc work firr which thc Jrcrmit is issucd. <br />_l havr: and will maintain workcrs' comJrcnsation insurancc, as rcquircrl by Scction 3700 of thc Lahor Codc, lor thc Jrcrftlrmance of <br />thc work ftrr which this pcrmit is issucd. My workcrs' conllrcnsation insurancc carricr and Jnlicy numbcr arc: <br />that in thc pcrtirrmancc of thc work tirr which this Jrcrmit is issucd. I shall not employ any pcrson in any manncr <br />subject to thc workcrs'comSrcnsation laws of Calililrnia, and agrce that if I struuld bcconr suhject to thc <br />workcrs' conrpcnsation provisions of Scction 37U) of thc l-atxlr Ctxlc, I shall, tilrthwith comply with ttxrsc provisions. <br />WARNING: Failurc to sccure workcrs'comJrcnsation covcragc is unlawtul, and shall subjcct an cmploycr to criminal grcnaltics and <br />civil lincs up to ollc hundrcd tlrousand dollars (S100,m0), in additionlo thc cost of compcttsati<ln, damagcs as providcd tirr thc <br />Scction 1076 of thc lahrr Ctxlc, intcrcst and attorncy's l'ecs. <br />Datet q'-?1 '2c' <br />DECLARATION <br />I hcrchy atlirm undcr pcnalty of prjury that I arn liccnsed under pnrvision of Chaptcr 9 (comnrcttcing with Seclkrn 7firu) of Division 3 <br />of thc Busincss and Pnrfcssion.s C<lde, and my liccnsc is in tull tilrcc and cll'cct. <br />Liccnsc Class: Liccnse Numbcr: <br />Contractor: <br />W <br />I hcrcby aflirm utrdcr JEmlty of perjury that thcre ir s q)mtructhn hrling a8crcy for th. grrfomme of thc work fur which this lEf,nit is <br />issucd (Scc. 1097, Civ. C.). <br />bnder's Namc: <br />l.cndcr's Addrcss: <br />APPLICANT DECLARATION <br />I trcrcby afiirm undcr Jrcnalty of pcrjury onc of thc tillluwing dcclarations: <br />Dcmolition Pcrmits-Asbcstos Notification Fcderal Regulations (Titlc 40, Part6) <br />-Rcquircd <br />lrtter of Notillcation <br />ahovc mcntioncd propcrty lor insJrcction <br />with all City and County <br />and County to cnter ugxrn thc <br />q'11-zc> <br />Applicant or Agent <br />Penrritee rlAnre <br />tlt I)ate: <br />Set Backs <br />Forms/Stee!/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bf loor/Ve nt/l ns u latio n <br />Roof Sheathinq <br />Shear Wall <br />Framing <br />Insu lation/Enerqy <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 />-- <br />FINAL [/,KA (-/*Nflo> v,t7 <br />Certificate of Occupancv <br />Notes, Remarks, Etc. <br />ne '-2n1 <br />a