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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby slfirm uilcr lEnalty of pcrjury thal I am excmJrl liom thc CoDlrsckrB' Liccnrc ku l(rr thc tirllowirg rcavrn (Ss.70]1.5 <br />Busrncss anl Profcssi(rn Cdrc): Any City or Counly which rcquircs a pmit k, c(rnslrucl. allcr. imp(rve. dcm)lish or Epai, any <br />struclurc, prbr k) its issuuncc, also rcquires llrc applicant fi)r such lErmit kr filc a signed stutcmnt lhal hc or shc is liccnrcd pursuant <br />lo thc pn)visions of thc Contrackn's Liccnsd hw (Chaptcr 9, Commcncing witlr ScclioD 7000 of Division 3 of lhc Busincss md <br />Pnrlcssions CorJc) or that hc or shc is cxcmpt thcrcfrom and thc basis li)r thc allcgcd cxcmpli(rn, ADy violation ofSe-titu 7031.5 by any <br />applica[t li)r a lrc]mit subjccls thc applicant b d civil pcmlty of not m)rc than tivc hundrcd dollsrs ($5U)). <br />_1. as owtrcr ol'thc propcrty, or my enlployccs with wagcs as lhcir solc conlpcnsation, will do lhc work atil thc slructurc is not <br />intcndcd or otTcrcd tbr sale (Scc.7044, Business and Profcssions Ctxlc: Thc Contraclor's Liccnse l;tw docs not dpply to an owncr of <br />thc pr<rpcrty who huilds or impnrvcs thcrqln, and who tlrcs sttch work himsclf or hcrsclf rlr thnrugh his or hcr own cmployccs, <br />provirled that such impnrvcrncnts are not intcndcd or ollbrcd lirr sah. Il. howcvcr, thc building or imprr>vcrncnt is sokl within onc ycar <br />ol'complction, thc Owner Buiklcr will havc thc hurrlcn ol'proving that hc or shc did not build rlr impruve thc propcrty lbr thc purplsc o[ <br />salc). <br />_1, as owncr of thc pR)lrcrty, am exclusively contracting with liccnscd contractors lo construct thc projcct (Sec. 7M4, Busiltcss <br />aml Prolbsskln Codc: Thc Contractor's License Law docs not apply l() an owner of propcrty who builds rlr imprcvcs thcrcon. <br />and who contracts tirr such projects with a Contractor(s) liccnsctl pursuant to thc Contractor's Liccnsc hw). <br />_l am cxcmpt undcr Scction-, B. & P.C. lirr this rcason. <br />Owner: <br />WORKERS'CONTPEN <br />DECLARATION <br />I hcrcby afl'irm undcr pcnalty of pcrjury onc of thc folkrwing dcclarations: <br />_l havc arxl will maintain a Ccrtiticatc of Consent to Sclt'-lnsure filr workcrs' compcnsation, as providcd tbr by Scction 3700 of thc <br />l^ahlr Culc, tbr the pcrlbrmancc of thc work for which thc pcrmit is issued. <br />W*;and will nraintain Scction -17(X) ol'thc Lahor Codc, Iirr thc pcrtirrmancc of <br />carricr and pllicy numbcr arc:lirr which this <br />rl /r lt0A\Policy <br />qq \ <br />_l ccrtil'y that in thc Jrcrlirrrnancc of thc work lirr which this Jrcrmit is issucd. I shall nol cntploy any [rcrson in any manncr <br />so as to bccomc suhjcct <br />workcrs' ctlmpcnsation <br />to thc workcrs'compcnsation laws of Calitirrnia, antl agrec lhat if I stxluld bccornc suhjcct to thc <br />provisions of Scction 1700 of thc Lahrr Codc. I shall.with thosc provisions. <br />WARNIN(}: Failure to sccurc workcrs' comJrcrrsation covcragc is unlawlirl. and an cmployer to criminal Jrcnaltics and <br />civil tincs up to onc hundrcd thousand dollars to thc tlamagcs as pnrvided tirr thc <br />Scction 3076 ol'thc [-ahrr Codc.and attrlrncy's <br />\4.0 t@ <br />DECLARATION <br />I hcrcby atlum undL'r pnalty ot'prjury lhat I anr licenscd urrdcr prcvision of 9 (cornnrcncing with Scction 7UX)) of Division -] <br />ol' thc Busincss and Pnrl'cssions Codc, arxl my liccnsc is in ttll tirrcc anJ cl'l'cct. <br />Zq q5 \{3LiccnscNumbcr: <br />\o <br />I hcrchy altrmuN-lcr IEMltyof pcrjury lhat thcrc is a construclion lcndilg ngcNy fi)r thc Jrcrti)rnrancc of thc w(uk lbr which this lsmit is <br />issucd (Scc. 3097, Civ. C.). <br />kndcr's Nanrc: <br />[-cndcr's Addrcss: <br />APPLICANT DECLARATION <br />I hcrcby allirm undcr pcnalty of Jrcrjury orrc of thc firlkrwing rlcclarations: <br />Dcmolition Pcrmits-Asbcstos Notilication Ferlcral Rcgulations (Titlc 40, Part6) <br />-Rcquircd <br />lrttcr of Notification <br />_l ccrtily that thc l'cdcralrcgulations rcgarding asbcstos rcmovalarc not applicablc to lhis projcct. <br />and statc that lhc alxlve inftlrmatiott is with all City and County <br />and County lo cnter ugrn thc <br />abovc mcntioncd propcrty tirr <br />Applicant or Agent <br />Pennitee rtanre <br />and hcrcby <br />0 Zu u <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf Ioor/VenVI nsu lation <br />Roof Sheathinq <br />Shear Wall <br />Framing <br />!nsu 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 />Enqineer Final Report <br />Flood Zone Certif. <br />FINAL tz /to /tn*tl r'f <br />Certificate of Occupancy <br />Notes, Remarks, Etc <br />Flarr fiP.-n7 -2n 1 q