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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/S!G.COMMENTS OWNER BUTLDER DELCARATION <br />I hcrcby atlirm undcr pcnalty of Jrcrjury that I am cxcmpt fiom lhc G)ilractos' Liccn* law tirr thc folhwilg rcavrn (Se.7031.5 <br />llusincss arkl P(rlbssi(u Codc): Any City or Coutrty which rcquircs a JErmit kr conslrucl. altcr. imp(rvc. dcmolish or rcpair any <br />slruclurc. pri)r k! ils issuancc, also rcquircs thc annlicanl for such JTrmit to filc a si8rcd slalcmnt lhnt hc or shc is liccnsd pusuant <br />to thc provisions of thc Contracbr's Liccnrcd law (Chaptcr 9, Grmmcncing with Sccti(,n 700O of Division .l of lhc Busircss and <br />Prolbssi(rnsG)dc)orlhatlEorshciscxcnrptlhcrcliomardthcbasistirrthcallcscdcxcmption. Anyvi(rlationofs(tiq70-ll.5hyatry <br />applicail ti)r a Jrcrmit subjccts thc applicant to a civil pcmlty of n(rl morc lhil tivc hundrcd dollss ($5(,o). <br />_1, as owncr ol'lhc propcrty, or my cnlployccs with wagcs as thcir solc compcnsation, will do thc work anl thc structurc is not <br />inlcrxlcd oroll'ercd lilr salc (Sc'c.7044. Busincss and Prol'cssions Crxlc: Thc Contractor's License Lrw drrcs not apply lo an owner of <br />thc prrrp*.^rty who huikls or improvcs thcrcun, and wh() rJrrcs such work himsclf rlr hcrsclf or lhrough his rlr hcr own cmployccs, <br />providcd that such imprcvcrncnls arc not intcndcd or ollcrcd tilr salc, Il, howevcr, thc huilding or improvcnrcnt is sold within onc ycar <br />ol'complction, thc Owncr Builder will havc thc burtlen ol'pnrving that hc or shc did not build or improvc thc pnrJrerty lirr thc purf)sc ol <br />salc). <br />_1, asownerof the prolrcrty, amcxclusivclyconlractirrg with liccnscd conlractorstoconstruct thc projcct (Sec. 7(X4, Busincss <br />antl F\otbsskln Codc: 'fhe Contractor's Licensc Law docs not apply to an owner of prcJrcrty who huikls or improvcs thcrcon, <br />and who contracts lilr such pro.jccts with a Contractrlr(s) liccnscd pursuant to thc Contractor's Liccttsc Law). <br />-IamcxemptundcrScction-'ts.&P.C.lilrthisrcastrn. <br />WORKERS' CONTPENSATION <br />DECLARATION <br />I hcrchy alTirm undcr Fnalty of Jrcr.jury onc of thc lirlkrwing dcclarations: <br />_l havc anl will maintain a Ccrtificatc of Conscnt to Sclf-lnsurc lirr workers' comJrcnsation, as providcd tbr by Scction 3700 of thc <br />l,atxrr Ctxlc, lilr thc ;rcrfrlrmance of thc work for which thc pcrmit is issucd. <br />_l havc and will maintain wrlrkcrs' comJrcnsatiorr insurancc, as rct;uircd by Scction .17()0 of thc Lahor Codc, tilr the pcrtirrmancc of <br />thc wrlrk lbr which this Jrcrmit is issucrJ. My workcrs' comlrcnsaliorr irtsurarrcc ciuricr and Jxrlicy nuntbcr arc: <br />r <br />IPolicy <br />_l ccrtily that in thc JrcrfirrmancL'ol'thc work lirr which this Jrcrmit is issucrl, I shall not cmploy any lrcrson in any manncr <br />so as to bccomc subjcct to thc workcrs' compensation laws of Calililrnia, and agrcc that if I shoukl bccomc subject .t thc <br />wrlrkcrs' comJrcnsation provisions of Scction 17fi) of thc Lahlr Crxlc, I shall, forthwith comply with thosc pnrvisions. <br />WARNTNG: Failurc lo sccurc wrlrkcrs' comJrcnsation covcragc is unlawtirl,sub.jcct an cnrploycr to crimin:rl Jrcnaltics and <br />civil lincs up to orrc hundred thousand dollars ($lm.Uru), in adtlition damagcs as providcd firr thc <br />DECLARATION <br />I hcrcby aUrm undcr pcnalty of 1^*rjury that I am liccnrcd undcr provision of Chaptcr 9 (commcncing with Scction 7U)()) of Division .1 <br />ol' thc Busincss and Prol'cssions Codc. and my liccnsc is fur tull ftrrcc anl cfl'cct. <br />Liccnsc ,L <br />lr <br />I hcrcby aftrm unrlcr Jrcnalty of pcrjury that therc is a construction hnding agency ti)r <br />issucd (Scc. 3097, Civ. C.). <br />[.cndcr's Namc: <br />Jrcrtilrmancc ol'thc work lilr which this pcrmit is <br />[,cndcr's Address: <br />APPLICANT DECLARATION <br />I lrcrcby allirm undcr pcnalty ot'Jrcrjury onc of thc lirlkrwing dcclaratiorrs: <br />Dcnxrlition Pcrmits-Asbcstos Notit'ication Fcdcral Rcgulations (Titlc 40. Pafl6) <br />_Rct1uircd kttcr of Notitrcation <br />with all City and County <br />and Counly to cnlcr upln tlrc <br />(1ll1 l).^^,--A <br />. _l ccrtity that thc l'cdcral rcgulatiorrs rcgarding asbcslos rcmovalarc not applicablc to this projcct.\- <br />D <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenVl nsu lation <br />Roof Sheathinq <br />Shear Wall <br />Framing <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif. <br />FINAL rulq u WY?Cl <br />Certificate of Occupancy I <br />Notes, Remarks, Etc. <br />Flarr n9*n7 -2n 1 q <br />ol'thc and <br />0