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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/S!G.COMMENTS OWNER BUTLDER DELCARATION <br />I hcrcby allirm undcr Fnalty of pcrjury lhat I am cxcmpt ftom lhc Cotrlractos' Liccns Lrw for thc lollowinS rcovrn (Scc.70.ll.5 <br />Ilusincss an1 Prolbssi([ Codc): Any City or County shich ]equircs a lrcrmit kr conslruct. altcr, improvc. demtlish or'rcpair any <br />structurc, prilr to ils issuaree, also rcqutcs thc applicant Ior such lrc(mit to tilc a signcd statemnt thal hc or shc Ls liccosd pusant <br />to rhc ln)visions of thc Contractor's l-icctrsd llw (Chrptcr 9, Commcncing with Scction 7(X)O ot Division .] ol thc Busiress od <br />PrclcssiuN Codc) or rhar hc or shc is cxcmpt thqcfrom and the basis li]r thc alhgcd crcmlilk)n. Any vi(]lation of Scction ?0.11.5 by any <br />applicarl lirr a lrcrmil $uhjccts thc aPplicant to a civil pcnalty of not morc than tivc hundred dollars ($500). <br />-.1, <br />as owncr ol'thc propcrty, or my cmployccs with wagcs as thcir solc compcnsation, will do thc work atd thc structurc is not <br />urtc-mlcd or ollercd lrlr salc (Scc.7044, Busincss anrl Prol'cssions Ctxlc: Thc Contractor's [-icense [-aw tlocs not apply to an owncr of <br />thc pnrJnrty wlxr builds or improves thcrcrrn, arxJ wtxr drrcs such wrlrk himsclf or hcrsclf or through his or hcr own cmpkryccs. <br />providcrl that such improvcnrcnts arc mlt intcndcd or oll'crcd tirr salc. Il. howcvcr, thc huikling or improvctncnt is sokl within onc ycar <br />ol'complction, lhc Owncr Buildcr will havc the burdcn ol'prcving that hc or shc did not build or improvc thc proJrcrty ltrr thc puryxrsc of <br />salc). <br />_1. as owner ol'thc pr)pcrty, am cxclusivcly contracting with liccnscd contractors lo construct the projcct (Scc. 7044, Busincss <br />and l'totbssion Codc: 'fhc Conlraclor's Liccnsc Law docs not apply to an owner of proJrcrty who builds or improvcs lhcrcon. <br />and who contracls lilr such projccts with a Contractrlr(s) liccnscd pursuanl to thc Ctuttractor's Liccnsc Law). <br />-IamcxcmptundcrScctiott-'B.&P.C.lilrthisrcason. <br />WORKERS' CO[\I PENSATION <br />DECLARATION <br />I hcrcby alf irm untlcr Jrcnalty of pcrjury onc of the tirllowing dcclaratiruts: <br />_l havc arxl will maintain a Ccrtilicatc of Consclrt to Sclt'-lnsure lirr wrlrkcrs' comJrcnsation, as providcd tbr by Scction .]700 of thc <br />Lahrr Crx.lc, for thc pcrlirrmancc of thc work for which thc pcrmit ls issucd. <br />*#iir:Scction 1700 of thc Labor Codc, firr thc pcrlilrmancc of <br />carricr and grlicy numbcr are: <br />illrlzoPolicyUI\ <br />$9f "cniry <br />rfrat in thc lrcrformmr of thc work for which this Frmit is issucd, I shall not cmploy any;rrson in any manrcr <br />$ as k) hccom subjcct to thc qxkcrs' comJEnsalion laws ofcalitbruia, and agrc lhal if I slxrutl bqcom subi*t to thc <br />workss' comFnsati(rn provisions of Setion 37U) of thc Latnr Cqlc, I slBll, fonhwilh crmply with llxrs prrvisions. <br />WARNING: Failurc lo wre workcrs'comlEnsattrn Lrrvcmgc is unlawlul, and shall subjet an cmpk)ycr to siminal lrcEltics and <br />civil lincs up to onc hundrcd th<lusarrd dollars ($lm.Om), in atldition lo thc cosl ol'com;rcnsation, damagcs as providcd filr thc <br />attorrrcy's <br />ol ision lI hcrcby allum untlcr pcnalty of pcr.iury that I am liccnsctl undcr provisiott of Chaptcr 9 (commcncing with Scctirln 7fiX)) ot' <br />of thc Busincss and Prot'cssions Codc, and my liccnsc is in full lilrcc and cttcct. <br />C to 171 5b I <br />Liccnse Nunrbcr: <br />0 Vt <br />W <br />I hcrchy allfum undcr Fnalty of fErjury that thrc is I c$nstructbn hnding agcrey for the tErfotmrec of thc work for which this Ismit is <br />issuctl (Sec. 309?, Civ. C.). <br />hndcr's Namc: <br />[rndcr's Ad&css: <br />APPLICANT DECLARATION <br />I hcrcby atl-rm undcr pcnalty of Jrcrjury onc of thc ftrlkrwing dcclaratiorts: <br />Dcrnolition Permits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40, Part6) <br />_Rcqu rrcd lrttcr ol' Notification <br />_l ccrtily that thc <br />Ntq.""ity that I havc <br />l'crlcral rcgulations rcgauding astrcstos rcnxlvalarc not applicahlc to this pnrjcct. <br />rcad this and stale that thc atxrvc itttirrmatiott <br />ordinanccs antl Statc l-aws rclating to <br />abovc nrcrrtioncd propcrly lirr <br />t. <br />Applicant or Agent <br />construcliott, atxl <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenVI nsu lation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Energy <br />Drvwall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonrv <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif . <br />,I <br />FINAL ul h,l 0/+vw <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />Elarr nP.-n7-2n16 <br />as hy <br />Tvvt <br />Scction .1076 <br />D LO