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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->