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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG,COMMENTS OWNER BUILDER DEI.CARATION <br />I hcrcby aft-rm uklcr Fnalty of Frjury IhaI I sm cxcmpt liom lhc Cotrtrackrrs' Liccnsc tlw ti)r thc tbllowitrg rcasrn (Scc.7031.5 <br />Busincss dnl Profcssion Cqlc): Any City or County which rcquires a Jrrmit k) construct. ,ltcn improvc. demolish or rcpair any <br />structurc, [ri!r lo its issu!rec, also rcquires lhc applicant tor such lErmit k] tilc a siSncd statcmnt thrt hc or shc is liccnsd pursuanl <br />to thc pruvisions of thc G)ntraclor's Liccnscd [lw (Chaptcr 9, Commcnciug with Sccti(tn 7fi)0 of Division .l of lhc Busincss aml <br />PnrlbssiorrsCodc)orthathcorshciscxcmptthcrchomatrdlhcbasisforthcallcgcdcxcmption. AnyvidrtionofscctiuT0Jl.5byany <br />applicant lbr a Frmit suhjccls thc applicant k) a civil pcnally of n(tt morc than livc hundrcd dollus ($5(,()). <br />_1, as owncr ol'thc propcrty, or nly cmployccs with wagcs as lhcir solc comgrcnsation, will do lhc work aml lhc structurc is nol <br />intcndcd or ollbrcd frlr sale (Scc.7044. Busincss and Prot'cssions CrxJc: Thc Contritctor's Liccnsc Law dtrcs not apply to an owncr of <br />thc pnrJrcay who builds or in'lpn)vcs thcrcon, and who drrcs such work himsclf or hcrscll or thn)ugh his rlr hcr own cmployccs, <br />providcd that such improvcrncnts arc not intcndcd or otfcrcrl lirr salc, Il, howcvcr, thc huildinet or improvcmcnt is sold within onc ycar <br />o[complction. thc Owncr Buiklcr will havc thc hurdcn o[proving that hc or shc ditl mrt build or improvc thc pnrgrcrty for the puqxrsc of <br />salc). <br />_1, as owncr ot'thc propcrty, am cxclusivcly contracting with liccnscd contractors to construct thc projcct (Scc. '7(J44, Busiltcss <br />arxl hutbssion Corle: Thc Contractor's <br />and who contracts tor such projccts <br />Law docs lrot apply to an owncr of proJrcrty who huilds tlr improvcs thcreon. <br />liccnscd pursuant to thc Contractrlr's Liccnsc Law). <br />_l am cxcmpt this <br />DI.]('I,ARAI'I()N <br />I hcrcby all'irm undcr pcrulty of Jrcrjury one of the lillkrwing dcclaralions: <br />_l havc and will maintain a Ccrtilicatc of Consent to Sclt-lnsurc tirr workcrs' comJrcnsation, as providcd tilr by Scction 1700 of thc <br />latxrr Crxlc, lirr thc pcrlbrmancc of thc work tirr which thc prmit is issucd. <br />_l havc and will maintain workcrs' comJrcnsation insurancc, as rcquircd by Section -37ffi of thc Lahor Cttdc, lbr thc Jrcrtormancc of <br />thc work for which this Jrcrmit is issued. My workcrs' compcnsation insurance caricr anl Jxllicy numbcr arc: <br />Policy <br />_l ccrtily that in thc pcrtirrmancc of thc. work lirr which this Jrcrmit is issucd. I shall not cmpkly any pcrson in any manncr <br />so as to bccomc sub.icct to thc workers' compcnsation laws of Calitornia, and agrcc that if I stx.luld hccomc suhject trl thc <br />workcrs' comJrcnsation pnrvisions ol'Seclion 3700 of thc comply with tlxlsc pntvirions. <br />IVARNING: Failurc to sccurc workcrs' cornlrcnsation covcragc subjcct an cnrpkrycr to crintinal pcnaltics and <br />compcnsation, damagcs as providcd tirr thccivil lincs up t() one huntlrcd thousand dollars ($ <br />Scction 3076 ot't[c Lahy'Culc, <br />r)nre: rgh /4/ <br />intcrcst and attrlrncy's <br />- ,/.7 <br />I)E('l,ARA1'lON <br />I hereby allrm undcr Jrcnalty ol'pcrjury that I anr liccnscrl undcr provisiort of Chaptcr 9 (comnrcttcilrg with Scctittn 7000) ol'f)ivision 3 <br />ol' thc Busincss and Prlfcssions Ctxlc', arxl my liccnsc is in hrll lirrce and cll'cct. <br />Liccnsc Class: Liccnsc Number: <br />l)atc: <br />CONSTRUCTION LENDING AGENCY <br />I hcrcby aflirm undcr JEBlty of Frjury that ttm is a construction lcndinS agcncy for lhe pcftbrmnce of thc work for which lhis Frmit is <br />issucd (Se. 3097, Civ. C.). <br />kndcr's Namc: <br />I-ender's Addrcss: <br />APPLICANT DECLARATION <br />I lrcreby allirm undcr pnalty of pcrjury onc of thc lirlklwing dcclarations: <br />Dcmolition Permits-Asbcstos Notil'ication Federal Rcgulations (Title 40, Part6) <br />_Rct1u ircd lrttcr of Notilication <br />_l ccrtily that lhc asbcst<ls rcmoval arc not applicablc to this pnrjcct. <br />_l ccrtily that I have rcad thc ahlvc <br />atxrvc mcntioncd pnlpcrty lirr <br />Applicant or <br />Pennitee nanre <br />attrl <br />County <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bf loor/Ve nt/l ns u latio n <br />Roof Sheathinq DkE 17 <br />Shear Wall <br />Framinq <br />lnsu Iation/Enerqy <br />Drvwall <br />Ext./lnt. Lath <br />Brown Coat <br />IVIasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />tl tl-,// <br />FINAL IL 'lr lz 'ua DWTI ) <br />Certificate of Occupancy <br />Notes* Rerrarks, Etc I <br />1r0 '-0 7 <br />Flnrr nQ-n7 -2n 1 q <br />I I <br />I <br />t> <br />I