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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION <br />I hcrchy affrm undcr Jrcmlty of fErjury lhal I m cxcmpt from lhc Conlracbs' Li{cns llw for thc ftrlkr*ing rcasrn (Sec.70J 1.5 <br />Busincss anl Prulbssion Gxlc): Any City or County which rcquircs o lrrmil k) construct. altcr. imprcvc, dcmlish or rc[[ir any <br />structurc, prior k, its issuancc, also rcquires thc applicant lor such lrcmit to lilc a sigtrcd statcmc[t that hc or shc Ls liccnsd pusuant <br />lo Ihc prrvisions of thc CoDlractor's Liccnscd law (Chanlcr 9, Commcncing with Selion 7m0 of Division J of thc Business and <br />Prufcssions Codc) or that hc or shc is cxcmpt Ihsclrum aftl thc basis for thc allcged cxcmplion. Any violation of Sectirtn 70.}l.5 by any <br />applicant lbr a Fmit subjsts thc applicant to a civil Ircnalty of not morc than fivc hunlrcd dollars ($500). <br />_1, as owncr of thc propcrty, or my cmployccs with wagcs as thcir solc comgrcnsalion, will tlo thc work anl thc strr^"*turc is not <br />intcndcd or ol'tercd ftrr salc (Scc.7044, Busincss and Prol'cssions Crxlc: The Contractor's Liccnse Law does not apply lo an owner of <br />thc pnrJrcrty who huilds or improves llrcrcon, and who drrcs such work hirnsclf or hcrsclf or tluouglt his or her owlt cmployccs, <br />providcd that such imprcvcrrnts arc n()t intenJcd rlr oft'crcd lirr sah. ll, txrwcvcr, thc buikling or improvcrrcnt is sokl within ()nc ye:u <br />of complctkrn, thc Owncr Buiklcr will havc the burdcn o[proving that hc rlr shc did not build or improvc the propcrty for thc purp.rsc ol' <br />salc). <br />o <br />_1, as owncr of thc propcrty, am cxclusively contracting with liccnscd contraclors to conslruct thc pnrjcct (Scc. 7(X4, Busincss <br />and Pntlbsskur Codc: The Contractor's Liccnsc Law docs not apply lo an owncr of proJrcrty who builds or intprovcs thercon, <br />and wlrt> conlracts lor such projccts with a Contractor(s) liccnscd pursuanl to thc Contractor's Liccnsc Law). <br />r1 <br />-IamcxcmptunderScctitln-,B.&P.C.forthisrcastrn'I)ate: <br />WORKERS' COI\TPENSATION <br />DECLARATION <br />I hcrcby allirnr undcr pcnalty of pcrjury onc ol'thc tollowing dcclaratiotts: <br />_l havc and will maintain a Ccrtificatc of Conscnt to Sclt'-lnsure tor workcrs' comJrcnsation, as providcd tirr by Section 3700 of thc <br />Latxlr Codc, tirr thc grcrlormancc of thc work trlr which thc pcrmit is issued. <br />_l havc and will maintain workcrs'comJrcnsation insurancc. as rcquirctl by Scctittn -1700 of thc Labor Codc, lilr thc Jrcrlilrmancc of <br />the work lirr which this grcrmit is issucd. My workcrs' comlrcnsation insurancc carricr and Jxllicy numbcr are: <br />a z 403s a 4.t{.zlPolicy <br />_l ccrtity that in thc pcrlirrmancc ol'thc wrlrk tor which this pcrmit is issucd. I shall not cmpkry any pcrson in any manncr <br />so as to bccome suhjcct to thc workcrs' compensation laws of Calilirrnia, and agrcc that if I should bccomc suh.icct to thc <br />workcrs' compcnsation pnlvisions of Scction 3700 of thc Lahrr Codc. I shall, lirrrhwith comply with thosc provisions. <br />WARNING: Failurc to secure workcrs' comJrcnsation covcragc is unlawful. anrl shall subjcct an cmploycr to crimfural Jrcnaltics and <br />civil lincs up lo onc huntlrcd thousand dollars (Sl00,U}()), in additkrn to thc cost of crtmpensatirtn, damagcs as providcd tilr thc <br />Scction <br />I herchy .l <br />of thc Busincss and Prol'essions Codc, arxl my liccnsc is in tull tirrcc arxl cffcct. <br />a D 6-tsrtozLiccrtscNunrbcr: <br />Dare')lo.l.Lo <br />W <br />I hcrcby allilm under lEnalty of JErjury that ttEe is a custruction lcndirg agcncy fur thc fqfolmNc of thc work for which this Jrcrmit is <br />issucd (Se. 3097, Civ. C.). <br />lrndcr's Name: <br />lrndcr's Ad&ess: <br />APPLICANT DECLARATION <br />I hcrcby allirm undcr pcnalty of pcrjury onc of thc lollowing dcclarations: <br />Dcmolition Pcrmits-Asbcstos Notification Fcderal Regulations (Titlc 40, Pafl6) <br />_Rcquircd Lcttcr of Notilication <br />-l <br />ccltify lhal thc fedcral rcgllations rcgar.ling asbeskts rcmvaluc not applicahlc to this pmj.!t. <br />fal cdity rhat I havc rcarl rhis application atrl strtc rhar rhc above inlormtiotr is conet. I a1rc to comply with all City and Counly <br />orlimnccs and Statc laws rclating to building construction, {fi| hcrcby aulhoria rclrc*ntalivcs ofthis City and County h cnts uFrn thc <br />abovc mcntioncrl propcrty lilr <br />Applicant or Agent <br />Pennilce rrarne ul= <br />x rxtu, r lO,l.ZO <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenVl ns u lation <br />Roof Sheathinq nltTkatPt q7 <br />Shear Wal! <br />Framing <br />lnsulation/Enerqv <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />lt/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />=_r <br />FINAL ll- 29-7.v Jlr5ffi <br />Certificate of Occupancv <br />Notes, Remarks, Etc. <br />Flnrr n9,-n7 -2O 1 6 <br />r.,rn.i,-r , alpl)Fe €r.t ^d