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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby atllm undcr lEnalty oI Jrrjury rhal I am cxcmpt from lhc G)nlraclors' Liccnsc tlw lirr thc tirlkrwirtg rcasn (Scc.70.ll,5 <br />Busincss anl Profcssion Gxlc): Any City or County which rcquircs a ;rrmi k, conslruct. altcr. improvc. rlemlish or rcpair any <br />structurc, Jrior l(, its issuancc, also rcquircs thc applicant tbr such lrcrmit k! lilc a signcd statcmnt thrl he or slE is lice[$d puBuant <br />to thc prcvisions of thc Contractor's Liccnscrl law (Chaptcr 9. Commcncing uilh Seti(tn 7(XX) of Division ., of the Busincss and <br />PnrtbssionsCodc)orthathc(xshcisexcmptthscfrcmatrdlhcbrsislirrthcsllegcdcxcmplion. Anyvi(llatiortofSectirmT03l.5byauy <br />applicanl for a Fmit subjccls thc applicant lo a civil pcnally of not more than fivc hundrcd dollars (5500). <br />_1, as owncr ol'thc propcrly, or my employces with wagcs as lhch solc com5rcnsation. will do lhc work atxl thc slnK'lurc is nol <br />intcndcd or oll'crcd tilr salc (Scc.7044, Busiltcss and Pnlfcssions Codc: Thc Contract()r's Licensc Law docs not apply lo an owner ol' <br />thc proJrcrty wtxl builds or improvcs thcrcun, and wtxr drrcs such work himself or hersclf or thnrugh his rlr hcr own employccs. <br />providcd that such imprcvcmcnts arc not intcndcd or oll'crcd lirr sale. I[ howcvcr, thc building or improvcrncnt is sold within one ycar <br />ol'complction, lhc Owncr Buildcr will havc thc burdcn ol'proving that hc or shc did not build or imprrtve thc propcrty ltrr thc purJxrsc ol' <br />salc). <br />_1, as owncr ol'the propcrty, am cxclusivcly contracting with liccnscd conlractors to construct thc proict (Scc. 7(X4, Busurcss <br />and PnrlbssionCode:I'hcContractor's Liccnsc [,awdocs not applyto anowncrof propcrtywho huilds or improves thercon, <br />and who contracls lirr such projccts with a Contractor(s) liccnscd pursuant to thc Contract<lr's Liccltsc Law). <br />-IanrcxcmpturuJcrScctitln-.B.&P.C.lilrthisrcasrrn.Date: <br />}VORKERS' CONT PENSATION <br />DECLARATTON <br />I hcrcby atl'irm under Fnalty of prjury onc of thc titlkrwing dcclarations: <br />_l havc and will maintain a Ccrtilicatc ol'Conscnt to Sclt'-lnsurc tirr workcrs' compcnsation, as providcd tirr by Section 3700 of thc <br />[-ah'or Ctxlc, tilr thc Jrcrlirrmance of thc work ftrr which thc pcrmit ls issucd. <br />_l havc and will maintain workcrs' compcnsation insurancc, as rcquircrl hy Scctkrn -17fi) of thc Labor Code, lirr thc Jrcrlirrmancc of <br />thc work lbr which this pcrmit is issucd. My workcrs' compensation insurattcc carricr and Jxrlicy numhcr arc: <br />Policy <br />_l ccrtity that in thc Jrcrtrlrmancc o[the wrlrk lirr which this ;rcrmit is issuctl, I shall not empkty any lrcrson in any manncr <br />so asto bcconrc sub.icct to thc workcrs'compcnsation laws of Calitilrnia, and agree that if I should bccomc subject tothc <br />workcrs' comJrcnsation provisions ol'scction 37fi) of thc Lahlr Ctxlc, I shall. li)rthwith comply with ttxrric provisions. u <br />WARNTNG: Failurc to sccure workcrs' comJrcnsation coveragc is unlawl'ul. and shall suh.icct an employcr to criminal Jrcnaltics and <br />civil lincs up to onc hundrcrl thousand tkrllars (Sl00.U}()), in addition to thc cost of crtmJrcnsatitln. damagcs as providcd tbr the <br />Scction .1076 ol'Codc, intcrcst and altrlrncy's l'ccs.\ <br />, <br />DECLARATION <br />I hcrcby allirm under pcnalty ol'pcrjury that I am liccnscd unrler provision of Chaptcr 9 (commencing with Scctirln 7firu) of Division 3 <br />ol' thc llusincss and Pnll'essions Code, arx.l my liccnsc is in full tbrcc utd cthct. <br />Liccnsc Numbcr: <br />\) <br />CONSTRU TION LENDING AGENCY <br />I lErcby allirm undcr fnulry of lrrjury that there is a constructkln bnding agcncy for thc trcrforronce of thc work for which this lErmit is <br />issued (Sc. 3097, Civ. C.). <br />[-cndcr's Addrcss: <br />APPLICANT DECLARATION <br />I lrcrcby allirm undcr Jrcnalty of perjury onc ol'thc lirlklwing dcclarations: <br />Dcmolitiolt Pcrmits-Asbcstos Notification Fcderal Rcgulations (Titlc 40, Part6) <br />-Rctluircd <br />l*ttcr of Notilicatkrn <br />_l ccrtity that thc t'cdcralrcgulations regarding asbcstos rcnxrval arc not applicablc to this pnlcct. <br />_l ccrtity that I have rcad this application and statc that lhc ahrve intirrmatiort is correct. I agrcc to comply with all City and County <br />ordinanccs and Statc Laws rclating to building construction, and hcrcby authorizc reprcscntativcs of this City antl County to cntcr uJxtn tlrc <br />ahruve mcntioncd propcrty ti)r <br />Applicant or Agent <br />Penrritee nanre <br />G o ra d <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenUl nsu Iation t <br />Roof Sheathinq ll lro lz;2A-ffi 7 <br />Shear Wall <br />Framinq <br />lnsulation/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 />n I <br />FINAL l1-l ( lz2 W,7 <br />Certificate of Occupancy I <br />Notes, Remarks, Etc. <br />Florr fi9'n7 -2n I q <br />[.cndcr's Namc: