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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUTLDER DELCARATION <br />I hcrchy afiirm undcr Fmlty of Friury thot I 0m cxcmpt lirm thc c(rntrackrff' Liccns tlw for lhc folkrwing rca$n (Scc.?031.5 <br />Busincss anl Protbssion Culc): Any City or County which rcquircs a lrcrmit lo coNlrucl. altcr. improvc. dcmolish or rcpair any <br />slruclurc, prior kr its issuancc. also rcquircs thc applicanl for such Frmit kr tilc a sigrcd statcmnt lhal he or shc is liccnsd pursuant <br />k) thc prcvisions of thc Contract(,r's Liccned Law (Chaptcr 9, Cummcncing eith Sccliur 7000 ot Divisi(tn J (tf thc Busircss and <br />P(rlcssions G)dc) or that he or shc is cxcmpl thcrcliom ard thc basis ti)r thc allcScd cxcmpti(nt. Any violation ofsccli(rn 7031.5 by any <br />applicdnt tbr a lrcrmit subjccts thc applicant k) a civil pcualty oi n(rt morc lhan five hundrcd dollus ($5(x)), <br />_1. as owncr of the propcrty, or my cmployccs with wagcs as lhcir solc conlpcnsation, will do thc work and lhc slru!*lurc is nol <br />intclrdcrl or ot'lercd lirr salc (Scc.7044, Busincss arrd Prot'cssions Crxle: 'l'hc Contractor's l-iccnsc Law drrcs not apply lrt an owncr of <br />thc pn)pcrty wlxl builds or improvcs thcrcon, aml who drrcs such wrlrk hinrsclf or hcrscll'or lhnrugh his rtr hcr own enrpkryccs. <br />providcd that such impnrvcnrcnts arc not intcndcd or oll'crcd lilr sale. Il, howcvcr, thc building ()r impn)vcmcnl is sold within onc yciu <br />ol'complction, tlrc Owncr Buiklcr will havc the burdcn ol'pnrving that hc or shc did not build or inrprovc thc propcrty tbr thc purJxtsc of <br />salc). <br />_1, as owncr ol'thc pnrJrcrty, am exclusivcly contracting with liccnsctl c()ntraclors t() construct tlrc prtjcct (Scc. 7044, Busincss <br />and Pnrfbssi<ln Code: 'fhc Contractor's Licensc Law drrcs not apply t() an owncr of proJrcrty who builds or improves thcrcon. <br />and who contracts lirr such pnljccts with a Contractor(s) liccnsed pursuant to thc Corttractor's Liccnsc Law;. <br />_l am cxcnrpt undcr Scction-, B. & P.C. for this reason. <br />I \... ^. <br />IVORKERS' CONI PENSATION <br />DECLAITATTON <br />I hcrcby atljrm undcr ;rcnalty ol'Jrcrjury onc of thc lbllowing dcclarations: <br />_l havc arxl will maintaitr a Ccrtiticatc of Conscnt to Sclt'-lnsurc lilr workers' comJrcnsation. as providcd tirr by Scction 3700 of thc <br />Labor Crxlc, lirr thc grcrlormancc of thc wrlrk lirr which thc Jrcrmit Ls issucd. <br />ZAhauc an l wltt mainlain workcrs comlEnsation insurdncc, as requircil by Scctio[ .]700 ol'lhc tlbor Codc, li)r thc lsfomancc of <br />L'ihE'wrrk tbr which this Jrcmit is isrucrl. My workcrs' comlrcnsntion insurane cmicr aul F)licy numbcr ue: <br />Policy +-f r Ist <br />I <br />_l ccrtily that in the p-rklrmance of thc work lilr which this pcrmit is issucd, I shall not cmploy any frcrson in any manner <br />so as to bcconrc suhjcct to thc wrlrkcrs'compcnsation laws of Calilbrnia. and agrcc that if I stxluld bccornc suhjcct to ttrc <br />workcrs' coml^*nsation provisions of Scction .17ffi ol'thc Lahrr Codc, I shall, lirrthwith comply with thosc pnrvisiotts. <br />WARNING: Failurc to sccurc workcrs'compcnsation covcragc is unlawlul, and shall subjcct an cmploycr lo criminal pcnaltics and <br />civil lines up lo onc hundrcrl thousand dollars ($100,UX)), in addition to thc cosl of'conrJrcnsation. rlamagcs as providcd tirr thc <br />Scction 1076 ol'thc CorJc, intercst and atlrlrncy's t'ccs. <br />I hcrcby allirm undcr Jrcnalty ol'Jrcrjury .] <br />ol' the Busincss and Prolbssiorrs Codc. arxl my liccttsc is in lfull lirrcc aml cll'cct. <br />Liccnsc t>Numbcr: <br />+b \,\ <br />CONSTRUCTION LENDING AGENCY <br />I hcrcby affum und$ Jrculty of lErjury that thcrc is a constructi)n lcnding agcrey for thc JtIfomrcc of lhc work for which lhis Ismit is <br />issucd (Scc. 3097, Civ. C.). <br />lxn lcr's Nam: <br />knder's Addrcss: <br />APPLICANT DECLARATION <br />I hcrcby all-rm undcr pcnalty of Jrcrjury onc of thc lblklwittg dcclaratiorts: <br />Dcmolition Pcrmits-Asbcstos Notitlcation Fcdcral Rcgulations (Titlc 40, Part6) <br />_Rctlurcd lrttcr of Notilrcalkrn <br />-l <br />certity that lhc lcdcral rctulations rcgeding asbcskrs rcm)val arc not applicablc k) lhis Prtjet. <br />Klcdity tnat I havc rea'l rhis applicstion arkl strte thrt thc ahovc intbrrutiou is corccl. I a!re to comply wilh all City and County <br />ordina\ccs and Statc bws rchting nr building construclion, anl lErcby aull$rizc rclrcsntalivcs oflhis City arkl County to cntcr uF)n thc <br />atxlvc mcntioncd proJrcrty ftlr <br />Applicarrt ur Agent <br />Penrrilee nanle <br />*,., Fr[ tr{/+ooo <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenUI nsu lation <br />Roof Sheathing <br />Shear Wall <br />Framinq <br />lnsu lation/Enerqv <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />lVlasonry <br />-Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif . <br />I ,)n <br />FINAL l? -lw 'n lkff6 <br />Certificate of <br />Notes, Remarks, Etc. <br />Flarr fiF.n7 -2n1q <br />fl <br />6av\E.+