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BUILDING. INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I hcrchy aftiril ututcr Fnrlty of Frjury that I m erempt liom lhc Conlraclors' Liccnrc ljw for lhc folbwing rcaurn (Ss.7031.5
<br />Busincss alrl Prolbssion C<xlc): Any City or County which rcquircs a lEmit k, cor$Irucl. altcr, improvc. dcmolish or rcpeir any
<br />structurc, fi)r b its issuancc, 0lso rcquircs the applicant lilr such JErmil to Iilc a signcd stalcm[l that hc or shc Ls liccnsd pusuant
<br />to thc pK)visions ()f thc Cotrhct()r's l-iccnscd [2w (Chaptcr 9, Commcucing with Sccti(n 7()00 of Division .] of lhc Busincss and
<br />PrcfcssirDs Codc) or th{t hc or shc is cf,cmpt tlrcrchom and thc hasis ti)r thc allcgcd cxcnrptiur. Any violalion of Scction 70J L5 by my
<br />{pplicanl tirr 0 pcrmit subjets lhc applicatrt to a civil pcnally (tf not morc than tivc hunrlrcd rlollars ($500),
<br />_1, as owncr of thc propcrty. or my cmployces wilh wagcs as lhcir solc compcnsation, will do thc work arxl thc stru!*lurc is not
<br />furtcrx.lcd or otl'crcd lbr sale (Se.,-.7044. Busincss and Prot'cssions Crxlc: Thc Contraclor's Liccnsc [-rw does not apPly to an owner of
<br />the- pnlpcrty who builds or impnrvcs thcrcon. alxl who drrcs such wrlrk himsclf or hcrsclf rlr through his or hcr owtt cmpkryces,
<br />providcd that such impnrverncnts arc m)t intcnded or otlbrcd tirr salc. It. howcvcr, thc building ()r improvcrncnt is sold withitr onc ycar
<br />of complction, thc Owncr Buildcr will havc thc hurdcn of proving that hc or shc did not huikl or improvc thc pruJrcrty lirr thc purposc of
<br />salc).
<br />_1, as owncr of thc proJrcrty, am cxclusivcly contracting with liccnsed contractors to construct thc projcct (Scc. 7(X4, Busincss
<br />arxl Pnrlbssion Codc: The Contractor's Liccnse Law docs not apply to an owner of propcrty who builds or imprcvcs lhcrcon,
<br />and who conlracts for such pnljccts with a Contractor{s) liccnscd pursuant to thc Conlractrtr's Liccnsc Law).
<br />-l
<br />am excmpl undcr Section-. B. & P.C. tbr this reason.
<br />Date:
<br />WORKERS' COIIT PENSATION
<br />DECT,ARATION
<br />I hcrchy all'irm undcr Jrcnalty of Jrcrjury onc of thc tilllowing tlcclarations:
<br />.-l havc arxl will maintain a Ccrtilicatc of Conscnt to Sclf-lnsurc lilr workcrs' comJrcnsati()n, as provided fbr by Section -1700 of thc
<br />latxrr Ctxlc. lbr thc Jrcrlbrmancc of thc work fbr which thc Jrcrmit is issucd.
<br />_l havc anrl will maintain workcrs' conrlrcnsatiolr insurancc, as rcquircd hy Scct ion 17fi) of thc Lahor Codc, lirr thc ;rcrlirrmance of
<br />thc work lilr which this permit is issucd. My workcrs' compcnsation insurance carricr and prlicy numbcr arc:
<br />Canier
<br />Policy Nunrbcr: Expircs:
<br />_l ccnily lhat in lhc lErlormtrec of thc work tbr which lhis prmit is issucd, I shall not cmlkty sny lErson in rtry matrncr
<br />$) as b hccom suhiel to thc sorkcrs' comlrcnsation lass of Cdliti)mia, and a8rc that if I slnruld tBu(tm suhF]-l t(t thc
<br />workcrs' comFDsalion provisions (r[ Sccliou 37fi) of thc lahr Gxlc, I sh{ll, fonhwith comply with tk}s pruvist)ns.
<br />WARNING: Iisiturc to scurc workcrs'compcnsation covcragc is unlawful, and shall subltrt an cmpklycr lo crimin0l [Enaltbs and
<br />civil lincs up k) orc hundrcd thousund rlollars ($1()0,m0), in additbn to thc cost of comJrcnsation, damagcs as providcd for thc
<br />Scction 3076 of thc Lahrr Ctxlc, intcrcst and attorncy's l'ecs.
<br />I hcrchy al't-rrm undcr Jrcnalty of Jrcrjury that I am liccnrcd under 9 (commcncing with Scction 7U}()) of Division 3
<br />ol' thc Ilusincss and Prol'cssiorts Codc, arnl rny liccttsc is irt litll lirrcc
<br />Liccnsc t
<br />W
<br />I hcrcby sllirm undcr lEnalty of lErjury that thsc is a constructkrr lcnding agcrey for thc pcrformancc of the work for which lhis Imit L$
<br />issucrl (Sec. .1097, Civ. C.).
<br />Lcntlcr's Namc:
<br />Lrndcr's Addrcss:
<br />APPLICANT DECLARATION
<br />I hcrchy atl-rm undcr pcnalty of pcrjury onc of thc lblkrwing rlcclaraliotts:
<br />Dcmolition Pcrmits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40, Part6)
<br />-Rct;u
<br />irctl [rttcr ol' Notilrcatiolt
<br />_l ccrtil'y that tlrc t'crleral rcgulations rcmovalarc not applicahlc to this projcct.
<br />-l
<br />ccrtil,v that I have'read this application thc atxrve inlirrmation is corrcct. I agrcc to comply with all City and County
<br />ordinances and Statc [:ws relating to arxl hcrcby authorize representativcs of this City and County lo cntcr uJnn thc
<br />abovc mcntioncd proprty firr insJrcction
<br />Applicant or Agent
<br />Pennilee nanrc
<br />,,,",1\ ll't/2.,
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />S u bf loor/VenVl n s u !atio n ,^\
<br />Roof Sheathing \z-*-vv I ulilllL F&frra lEJq
<br />Shear Wall t)\l
<br />Framinq
<br />lnsu lation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />[\Iasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />n\
<br />FINAL 12-1-ba hw),a
<br />Certificate of
<br />Notes, Remarks, Etc.
<br />fr), \tP,/
<br />Florr nR-n7-2n 1 q
<br />,*,, \tt?t 7->
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