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BUILDING. INSPECTOR RECORD <br />--rSITE.WORK DATE ID/SIG.COMMENTS Owncr-Builder I)eclaral ion <br />I hereby affirnr under pennlty of periury that I anr exenlpt fornr lhe Contractors' l,icense Law for the followtng reason (sec 703 L5 tlusiness <br />and Profession Code): Any ('ity or (ounty which requires a pennit to construct. alter. improvc. demolish or rcpair any structurc. prior to its <br />issuance.alsorequirestheapplicantforsuchpenniltofileasignedstal.mcnl lhathcorshcislicesed pursuanltothepnrvisionsofthe <br />Contraclor's [,icensed [-aw (('hapter 9. Conlmencing wilh Section 7000 olDivision 3 oflhe Business and Professronr Code) or that hc or <br />she is excmpt thcrcfrom and the basis for thc alle8cd cxcmplion Any violation ofScclion 703 1.5 by any applicant for a pcnnit subjccts thc <br />applicant to a ci|il penalty oInol ,nore lhan fire hundred dollars ($500). <br />I.as ouneroflhcpropcny.ormycmployeesrvithwagmastheirsolccompcnsalion.willdotheworkandthcslructurcisnotintcnded <br />or offered for $le ( Se 7044. Busrnes and Professions Code: The ('onlraclor's License Law does not apply to an owner ofthe propcny <br />who builds or impror'.s lhcrcoo. and who dod such work himsclfor hcreclfor throuSh his or her own cmployeG, providcd lhrt such <br />improvemcnls arc not intendcd or offcrcd for sale. lf. however. lhc building or improvcmcnt is sold within onc ycar ofcornpl.tion, thc <br />(\,ncr-Builder will havc thc burdcil ofproving thal he or sh. not build or improvc for lhc purpose ofsalc). <br />_1. as owncr oflhc propcrly. am cxclusively contractin,{ wilh liccnscd conlraclors lo conslrucl the project ( Scc. 7044, Busincss and <br />Profession ('oder The ('onlraclor's [.icense Law does nol apply to an owner ofpropeny who builds or inproves thereon . and who <br />contracls for such projects wilh a (bntraclor(s) licensed pursuanl to Ihe Contractor's [-icense Law ). <br />_l am exempl undcr Scction .8. & P.C. for lhis reason <br />Dale: _Os ner: <br />1VORKERS COIIPENSA'I'ION DI]('LARA'TION <br />I hereby amrn under penally ofperjury one ofthe follorving declarations: <br />I havc and will maintain a Cenificatc ofComent lo Sclf-lnsure for workers conrpenelion. as provided for by Setron -1?00 oflhe <br />trbor Code, for thc performance oflhe sork for which thc pcnnit is issued. <br />_lhaveandwillnrarnlainworkers conrpenelioninsur&nce.as requiredbySectron3T00ofthetaborCode.lortheperfornranceofthe <br />work for which thrs perfiit rs rssued My workers' compenstion insurance canier and policy nunber are: <br />('anier: <br />Policy Numher:l:xpir cs; <br />('IhissectionncednolbccompletediflhepcnnilisforOnehundreddollarsl$l00lofless) <br />I cenify lhal in the pcrformancc ofthe work for which this permit is issued. I shall not employ any pemon in any manncr so as lo <br />became suh.;ect to the workers' conrpensation laws of <br />compensation provisions ofScclion 3700 ofthe tabor, <br />lhat rf I should h€conre subJect to the workers' <br />I shall.rvith those provisions. <br />I)ate: <br />WARNINC Failure to sccure workers <br />fines up lo one hundrcd lhousand d(tllars <br />is unlawful. and shall subjrct an emplover to oiminal pcnallies and cir il <br />lo lhe cosl ofcompcnsalion. danrages as provided for thc Scction 3076 of <br />the Labor Code. inlerest and attorney s fees. <br />LICENSED CON'IRAC'TORS DECLARATION <br />I hereby aflirm under pcnally ofperiury thal I arn licensed under provision of(-hsptcr 9 (commencing with Scction 7000) ofDivision -1 ot <br />the Business and Professions ('ode. and mv license is in full force and effect <br />[-icense Class: <br />I )al(-l w <br />I hochy affim under pcnally ofpcrjury lhat <br />issucd (Sec. 3097. Civ. C.). <br />Lender's Nanie <br />agency for lhc pcrfomance ofthc work for which this pcrrnit is <br />Lender's Address <br />APPLICAN'I''S DECI,ARAT'ION <br />Dcmolition Peflnits-Asheslos Noli[icali(n lederal Regulalions ( l ille 40. Part 6) <br />Required t.etter of Notilicat ion <br />I certify thal lhe fcderal reSulalions rcgarding asbeslos removal 6re not applicable to this project. <br />I application and slate that the above information is corrcct. I agrce to comply rvith all Cily and County <br />conslruclion. and hcreby authorizc representativcs ofthis City and Counly to entcr upon the <br />It <br />atnve <br />ha\'e <br />lbr <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subfloor/VenUlnsul <br />Roof Sheathing <br />Shear Wall <br />Framing <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />[\4asonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />I <br />F!NAL lh/[/tu ffir71 I <br />Certificate of Occupancy t( <br />Notes, Remarks, Etc. <br />J< <br />pcrminesrr):a<il G;ZR