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BU!LDING- INSPECTOR REGORD <br />SITE.WORK DATE ID/SIG COMMENTS OWNER BTJILDER DEL$RATION . A <br />I hcrcby afftrm undcr Fnalty of lErjury lhat I m cxempt frcm the ContractoN' Liccns [rw for thc following rssn (Scc.703 1.5 <br />Busincss and Prcfcssion Codc): Any City or County which rcquircs I Jmit to construct. 8ltcr, improvc. dcmlish or rclBir oy <br />struclurc. prior to its issumc. also rcquircs thc applicant for such lErmil to filc I signcd slatemnt that hc or slrc is liccnsd F$uul <br />to thc Fovisions of IIE Cont!-.ctor's Licensd taw (Chaptcr 9, Commrcing wilh Selion 7000 of Division 3 of Ihc Busiress ud <br />PrcfcssionsCodc)orthatheorshciscxctr{rtlhcrcfromandthcbasisforthcollcgcdexemplion. Anyviolation(rfsEtionT03l.5byany <br />applicanl for a pcrmil subjcts thc applicrnt to a civil pcBlty of not mrc th4 fivc hundrcd doll{s ($500), <br />-1. <br />as owrrcr of thc 1ropcrty. or my cmployccs with wages as thcir sole compcnsalion. willdo thc work and thc structure is rrrt <br />intcndcd or offcrcd for sale (Scc.7044, Busincss and Professions Codc: The Contraclor's Liccnsc l-aw docs not apply lo an owncr of <br />thc proprly who builds or inrproves lhcrcrn. and who does such work himsclf or hersclf or through his or her own employees. <br />providcd thal such improvenrcnl.s arc not intendcrl oroffcred for sale. lf. howcrcr. thc building or inprovcrEnt is mld within one )rcar <br />of completion. thc Owner Builder will have thc burden of proving that hc or shc did not build or improve thc proprty for thc purynscof <br />salc) <br />_1, as owncr of thc propcrty. anr cxclusivcly contracting with liccnscd contrBctors to conslruct thc projcrct (Sec. "l(44, Business <br />and Profcssion Codc: Thc Contraclor's Licensc Law docs not apply lo an owner of propcrty who builds or improves thcrctrn. <br />and who corttracts for such projccts with a Contractor(s) liccnscd pursuant to thc Conlractor's Licensc Law). <br />_l am exempt under Section_, B. & P.C. for this reason. <br />Dete: Ormer: <br />WORKERS' COM PEIT{SATION <br />DECI {RATION <br />I hcrehy aflirm under penalty of pcrjury onc of thc following dcclarations: <br />-lhavcandwill <br />nraintainaCcrtificateofConscnttoSelf-lnsureforworkcrs'comFrensation.as gnovidcdforbySection3T00ofthc <br />[:bor Code, for the pcrfonnancc of thc work for which thc pcrrnit is issued. <br />_l havc arrd will rrraintain workcrs' conrpcnsalion insurarrcc. as rcquircd by Scct ion 37fi) of thc Labor Codc, lirr the pcrfonnarrcc of <br />the work for which this perrnit is issucd. My workcrs' con{rcnsation <br />carricr: ,/ ccl/ez 0/tn14,!r-/^ <br />insurancc carricr and plicy numbcr arc: <br />Policy <br />-l <br />ccrtify that in thc pcrformancc of thc work for which this pcrmit is issucd. I shall not cnrploy any pcrson in any rnnner i\ <br />so as to bcconrc subjcct to thc workers'compcnsation laws of Califonria. and agrcc that if I should hcconrc subjcct to thc <br />workcrs' compensation provisions of Section 37fi) of thc labor Code. I shall. forthwith comply with those provisions. <br />WARNING: Failurc to sccurc workers' compcnsation coveragc is unlawful. and shall subject an employcr to criminal pcnaltics arrd <br />civil fines up lo onc hundrcd thousand dollars ($100.000). in addition to thc cosl of compcnsatiorf. danrages as provided for rry; <br />attonrcy's fees. <br />I hcrcby afflrrn under pcnalty of Jrcrjury that I arn licenscd under provision of Chaptcr 9 (conrrnencing with Scction 7000) of Division 3 <br />of thc Business and Prol'cssions Codc. and my licensc is in ftll forcc and cffc'ct. <br />o/c)e46 -))cLiccnsc <br />, <br />Dale:/ <br />CoNSTRUCTION LM{DING AGENCY <br />I hcrcby aflinn udcr Fnallyof Jrcrjury that thc.c is a construction hnding ogcrcy for thc Frforrucc of thc work for which this tEnnit is <br />issucd (Scc. 3097. Civ. C.). <br />lxndcr's Nalrc: <br />knder's Address: <br />APPI ICANT OtrCT {*"ON <br />I horby afllrnr undcr pcnalty of pcrjury onc of the folkrwirrg dcclarations: <br />Demolition Pcrmits-Asbcstos Nolification Fcdcral Rcgulations (Titlc 40. Parl6) <br />-Rcquircd <br />l,cttcr of Notilicalion <br />-l <br />ccrlity that thc fbdcral rcgulations rcgarding asbcslos rcnmvalarc not applicablc to this projcct <br />_l ccrrify lhat I havc rcad this applicatiorr and statc that thc alxrve inlirnnatiorr is corrcct. I agrec to conrply with all City and County <br />ordhanccs and Statc laws rclating to building construction. and hcrebyauthorize reprcscntativcs of this Cityand <br />abovc nrcntioncd propcrty for <br />Applicant or Agent <br />Pernrilee name <br />purFroses. <br />cntcr u6rn tlrc <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loo rlY enV Insulation <br />Roof Sheathinq <br />Shear Wall <br />Framing <br />Insulatio nlEnergy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />lMasonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputv Final Report <br />Engineer Fina! Report <br />Fjood Zone Certif. <br />ftDt//A5 /{" l' r'V Atur'fui,V XlIVI <br />FINAL lPl"ao *{Ltffi ,tr <br />Gefiificate of Occupancy <br />Noteq Remarks, Etc. <br />Rev. 08-07-201 5 <br />iz <br />.Sccliort #44 ,rQ/{t