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BUILDING- INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BI'ILDER DELCARATION <br />I hcreby alfrm under Fnolly of Frjury that I u exetr{,t from thc CoilractoE Lkorc law for thc following uion (Sc<.7031J <br />Busincss and Pmfcssion Code): Any City or County which rcquires a Imit to constrct. .tlts, improvc" dcmolish or qnir ily <br />structurq prior lo ils issumc. als rcquires lhc alplicant for such pmit to fih a signed stalcrcnt that hc or shc is liccn*d pusill ' <br />to thc Fovisions of the Contretor's Lbenscd lzw (Chaptcr 9, Comrcing with Sction 7000 of Division 3 of the Busircss od <br />PrcfcssionsGrdc)orthathcorshcisexcmptthcrcfromardthcbr$[sfo]thcallcgcdcrcmption. AnyviolationofsetionT03l.5byilny <br />applicsnt for a lrcrmi! subj€ts tlrc applicant to a civil pcElty of not mrc thil fivc hundrcd dollus ($500). <br />-1. <br />as owrrcr of the fnopcrty. or my cmployecs with wagcs as thcir solc compcnsation. will do the work and the structurc is rnt <br />intendcd or otfcrcd for sale (Sec.7M4. Business and Professions Codc: The Contractor's Liccnsc law docs not apply to an owncr of <br />lhe proJrrty who builds or improves thcreon and who does such work himsclf or herself or through his or hcr own employees. <br />providcd that such improvcnrnts arc not intcndcd oroffcrcd for salc. lf. howcr,cr. the buikling or inprovcnrcnt is sold wilhin one )ryu <br />of complction. thc Owner Buildcr will have the burdcn of proving that hc or shc did not build or improvc thc propc.rty tbr thc purposc of <br />sale). <br />-1, <br />as owncr of the propcrty. am cxclusivcly contracting with liccnscd conlractors to construct thc projc'ct (Scc. 7M4, Busincss <br />and Prrolbssbn Code: Thc Contractor's Liccnse Law docs rrol apply to an owncr of proJrcrty who builds or improvcs thereon, <br />and who contracls for such pojccts with a Contracto(s) licenscd pursuant lo thc Contractor's Liccnsc [aw). <br />_l anr cxempt under Scction_. B. & P.C. for this reason. <br />l):rtt' <br />WORKERS' COMPENSATION <br />DECI ARATION <br />I hcrcby alfirnr undcr pcnalty of pcrjury onc of thc following dcrlarations: <br />_lhavcandwill nmintainaCerlificatcofConscntto.Sclf-lnsurelorworkcrs'comlrcnsation,as providcdforbyScction3T00ofthe <br />.Labor Code. <br />NH^,cand <br />for the pcrforrrance of the work for which thc Jrcrmit is issucd. <br />wi ll rrraintain workcrs'insurance, as by Scctiorr 3700 of thc labor Code. for thc performarce of <br />are:thc work which this pcrnrit is issurxl.workcrs'carricr aml plicy numbcr <br />U4 \Z <br />N thal in thc pcrforrnancc of thc work for which this pcrnrit is issucd. I shall not employ any pcrson in any manncr <br />so as to bcconrc subject to thc workcrs' compcns:llion laws of California. and agrce that if I should bcconrc subict to lhc <br />workcrs' compcnsation provisions of Section 3700 of thc l-abor Codc. I slull. forthwith comply with thosc provisions. <br />WARMNG: Failure to sccurc workcrs' cornpcnsation covcragc is unlawful. and shall subjcct an employcr to criminal penaltics and <br />civil fincs up lo one hundred thousand dollars in addition to thc cost ion. damages as providcd for thc <br />Scction 3076 <br />rrara. \ O T'TA I76""" <br />and <br />I hcrcby affirrn undcr pcnalty of perjury that I ant licenscd under of Chaptcr 9 (conrrrrcncing with Scction 7fi)()) of Division 3 <br />of thc Busincss and hofcssions Codc. arxl my license is in full force ard cffcrcl. <br />Licensc o to Nunrhcr: <br />q1 dsb <br />t <br />W <br />I lrcrcby rffirm undcr lrenalty of Frjury thal thcrc is a mnslruclion lcnding agcrcy for thc Jsfornuce of the work for which lhis lErmit is <br />issucd (Sec. 3097. Civ. C.). <br />Lrndcr's Narne: <br />lrndcr's Addrcss: <br />APPI ICANT NFCLARATION <br />I hocby affirm under Jrcnalty of pcrjury onc of thc following dcclarations: <br />Dcmolition Permits-Asbestos Notification Fcdcral Regulations (Title 40, Part6) <br />_Rcquired l,cttcr of Notificalion <br />_l ccrtify that thc fcderalregulations regardirrg asbcstos <br />l$""n,fy that I havc read rhis application and statc thar thc <br />rermrvalarc nol applicablc to this proJcct. <br />abovc information <br />ordinances and Statc laws rclating to <br />alxrvc nrcnlioncd propcrty firr <br />rt;lplicnnl or <br />I)crnritec <br />construction. and <br />Set Backs <br />Forms/Stee!/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenVl ns u latio n <br />Roof Sheathing <br />Shear Wall <br />Framing <br />!nsulation/Enerqy <br />Drywal! <br />Ext./lnt. Lath <br />Brown Coat <br />JVasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />FINAL I Ll? l'2 0 D**h <br />Certificate of Occupancy I <br />Notes, Remarks, Etc. <br />Rev. 08-07-201 5 <br />, <br />O"tu, \ O Contraclo r, V lvtnl- Sbt 4r <br />with all City and County <br />and County to enter u6rn thc <br />\D /iq l-o