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BUILDING- INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG COMMENTS <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/Ve nUl n su I atio n -l r <br />Roof Sheathinq ll ,0 Dq-*Y/ <br />Shear Wall I <br />Framinq <br />lnsulatio nlEnerqv <br />Drvwall <br />Ext./lnt. Lath <br />Brown Coat <br />Nlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />tl \^t)4 <br />(,/Ul{tdo,/FINAL <br />Certificate of Occupancy t <br />Notes, Remarks, Etc. <br />I hereby affirm undcr penalty of perjury that I am exempt from tlrc Cbntracton' License [-aw for the following reason (Sec.7031.5 <br />Busincss and Profcssion Code): Any City or County which requires a pcrmit to construcl, aller, irnprove. dernolish or rcpair any <br />structure, prior to its issualrce. also requires the applicant fkrr such pernilt to file a signed staterrcnt that he or she is licenscd pursuant <br />to thc pmvisions of thc. Contractor's l,icensed l:w (Chapter 9. Commcncing with Section 7fiX) of l)ivision 3 of the Business and <br />Prot'essi<lns Code) or that he or she is exempt therefiom and tlre basis for tlre alleged exemption. Any violation of Section 703 I .5 by any <br />applicant for a pennit subjects thc applicant to a civil penalty o[ not more than llve hundred dollars ($5tXl1. <br />of thc propcrty, or my employecs r*,ith wages as thcir solc compcnsalion, will do the work and thc slructurc is rnt <br />or offeretl for sale (Sec.7M4. Business and Professions Code: The Contraclor's License Law does not apply to an owner of <br />the propcrty who builds or ingows therooq and wtxl does such w<lrk himself or hcrself or through his or her own employees, <br />provided that such irnprovernents are not intended or ollercd for salc. Il. however. the building or improvcment is sold within one )€ar <br />of conpletion, the Owner Builder will havc thc burden of proving ttut hc or she did not buikl or improvc thc p.perty for tlrc purporc of <br />sale). <br />_1. as owner of the prcperty, am cxclusively contracting with liccnsed conlracloni to conslruct thc pr,oject (Sec. 7044. Busincss <br />and Pnrtbssirxr Code: The Contractor's License Law does not apply to an owncr of progrcrty who builds or improves thereon. <br />and who contracrs for such projects with a Contractor(.s) licenrcd pursuant to thc Contractor's Licensc l-aw). <br />_l anr cxempt under B. & P.C.-21 -'?e <br />I hcreby aflirm undcr penalty of perjury one dcclarations: <br />_I have and will maintain a Certificatc of Consent to Self-lnsure for workers' comgrcnsation, as provided for by Section 3700 of the <br />Labor Code, lor the Jrerformance of the work lbr which thc permil is issucd. <br />_l havc and will maintain workers' conrpensation insurance, as required by Section 3700 of the Labor Code, for the performarrce of <br />the work for which this permit is issued. My workers' compcns:rtion insurancc carricr ad plicy number are: <br />Carrier: <br />Policy Numtrcr: lixpires: <br />_l ccrtity that in the pcrfbrmance of thc work for which this prmit is issucd, I shall not cmploy any pcrson in any manncr <br />so as to becomc subjcct to thc workers' cornpensation laws of California. and agrcc that if I should becomc subject to thc <br />workers' conrlrcnsation pmvisions of Section 3700 of the Labor Code, I shall, forthwith comply with those provisions. <br />WARNING: Failure to sccure workers' comgrcnsation covcrage Ls unlawful. and shall suhject an employcr to criminal pcnahirx and <br />civil lines up to one hundred thousand dollars ($100,UX), in addition to the of damages as provided for the <br />Section 3076 of the l-abor C'ode, interest and attorney's fees. <br />Iratc:2-2?:bL?t <br />I <br />I hercby aflirm undcr penalty of pcrjury that I am <br />I)NCI,ARA'I'I0N <br />under provision ol'Chapter 9 (cornmcncing with Section 7ffn) of l)ivision 3 <br />of thc Busincss and Profcssions Codc. arxl my licensc is in full lirrce iurd etfcct. <br />l,icensc Numbcr: <br />I)ale: <br />CONSTRT.'CTION I,ENDING AGT:NCY <br />I hercby atfirnr under penalty of perjury that there is a construction lending agerrcy for the lrcrformarrce of the work for which this prmit is <br />issucd (.Sec. .3097, Civ. C.). <br />kndcr's Nantc: <br />f <br />[.cnder's Addrcss: <br />APPLICANT DECLARATION <br />I My affrnr under penalty of pcrjury one of the following declarations: <br />Demolition Permits-Asbestos Notification Fetlcral Regulatiorrs (Title 40. Part6) <br />-Required <br />[rtter of Notifrcation <br />_l certify that the federal regulations regarding asbestos renroval are not applicable to this project. <br />reatl this application and state that the above information is corrcct. I agree to comply with all City and County <br />representatives of this CitV3nd County to enter upon theand State l-aws relating to building constructiorta <br />atxn'e mcntioned pnrpcrty lirr <br />Applicanl or Agcnt <br />I)rrnritcr nanle <br />Purposcs. <br />atd autlxrrize <br />*r,, Z-21 -bZDt <br />Rev. 08-07-2015 <br />7Y, <br />lt