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BUILDING- INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf I oor/VenUI n s u Iatio n <br />Roof Sheathinq <br />Shear Wall <br />Framing <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />[\Iasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputv Final Report <br />Enqineer Fina! Report <br />Flood Zone Certif . <br />,- <br />FINAL lk^gnh JaL 3o bpq <br />Certificate of Occupancv <br />Notes, Remarks, Etc. <br />OWNER B UILI)IiR l)I.lLCA RA'I'I()N <br />I hcreby affirm under pcnalty of perjury that I am exempl from the Cbntractors' Licensc [-aw for the following rcason (Scc.7031.5 <br />Business and Prolbssion Codc): Any City or Countv which requires a Jrrmit to construct, alter. irnprove. dcmolish or repair any <br />structure. prior to ils Lssuancc. also requires the applicant for such prmit to file a signed staternenl that hc or she is licenscd pursuanl <br />to thc. pmvisions of thc Contraclor's Licen.sed law (Chapter 9, Comrnencing with Section 7000 of l)ivision 3 o[ the Business and <br />Prot'essions Code) or that hc or she is exempl therefrom and tlrc basis tbr the alleged exemption. Any violation of Section 7031.5 by any <br />applicnnt for a 1rcnnit subjects the applicant to a civil pcnllty of not more than five hundred dollars ($5tXl1. <br />_1. as owncr ol'the properly, or lny employces with wages as thcir solc compcnsation, willdo the work and thc structurc is not <br />intended or offered for sale (Scc'.7(X4, Business and Professions CtxJc: The Contractor's License Law docs not apply to an owncr of <br />the property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, <br />providcd that such imprrvernents are nol intended or olTered lbr sab. ll. howcver. thc buiHing or irprovennnt Ls sold within one ),ear <br />of conrpletion, thc Owner Buildcr will havc the burden of provirrg that lrc or she did not buikl or improvc thc propaty for tlrc purposc of <br />sah). <br />_1, as owner of thc propcrty. am exclusively contracting with licensctl conlractors to construct thc proFct (Scc. 7044, Business <br />and Prrolbssbn Code: The Contractor's License Law dtxs not apply to an owner of property who builds or improves thereon. <br />and who contracrs for such projects with a Contracto(s) licen.sed pursuanl to thc Contractor's Liccnse L:w). <br />_l am exempt under B. & P.C. ltrr this reason. <br />I t., r^. <br />W() R K I{) RS' COM I'I.INSATION <br />DECLARATION <br />I hcreby allirm undcr penalty of pcrjury one of the tbllowing dcclarat ions: <br />_I have and will maintain a Certilicate of Consent to Self-lnsure for workers' comyrn-sation, as provided for by Section 3700 of the <br />Lahor Code, for the Jrerformance of thc work for which thc Jrrmit is issucd. <br />_l have and as requircd by Section 3700 of thc l-abor Code, for lhe perforrnance of <br />thc work tbr insurance carrier ard policy number are: <br />Policy o 0t <br />_t certi$ that in thc Jrcrformancc of thc work for which this pcrmit is issucd, I shall not employ any person in any manncr <br />so as to becorne subjcct to thc workers' compensation laws of California. and agree that if I stnuld bccorne subject to the <br />worliers' comlrcnsation provisions of Section 3700 of the labor Code. I shall, forthwith cromply with tlrosc provisions. <br />WARNING: Failure to sccurc workers'compensation covcnrgc is unlawful. and shall subject an cmploycr to criminal pcnahies and <br />civil fines up to one hundrcd thousand dollars (Slm.(XX)). in addition lo lhe cost of comlrcnsalion. damages as provided for the <br />Section 3076 of the l-abor C'ode. interest and attorney's fees. <br />,,",", S(f!f 2o2r) <br />I-ICENSED CONTRA(:TOR <br />DECI,ARATION <br />I hereby alfirm undcr penalty oI perjury that I am licensed undcr provision of Chapter 9 (cornmencing with Section 70m) of Division 3 <br />of the Busincss and Profcssions Code, and my liccnse is in full lbrcc and cllbct. <br />License tL <br />CONSTRT.'CTION I,I.:NI)ING AGENCY <br />I hercby affrm under pcnalty of perjury that there is a construction lending agency fbr the perfonnarce of thc work for which this pcrmit is <br />issucd (Sec. 3097. Civ. C.). <br />Lrnder's Nanre: <br />l,cnder's Addrcss: <br />APPLICANT DECLARATION <br />I hercby affrm under penalty of perjury onc of the f<rllowing declaratiorts: <br />Demolition Permils-Asbstos Notification Federal Regulations (Title 40, Part6) <br />_Required lrtter of Notification <br />_l certify that thc fedcral regulatioru regarding asbcslos removal are not applicable to this proirl. <br />_l certify that I havc rcad this application and state that the abovc information is correct. I agroc to comply with all City and County <br />onlinances and State Laws relating to building construction anl hereby authorize rcprcsentatives of this City and County to enter upon the <br />alxrve mentioned propcrty lbr inspcction purposes. <br />Applicant or Agcnt r,.,"S rrffit%2l) <br />at <br />Bev. 08-07-201 <br />Pcnnitee