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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcrchy affum undcr lEnally of Frjury that I am cxcmpt hom lhc Conlracl()N' Liccnsc llw for lhc lolloviog rcasln (SR-.70.]1.5 Ilusincss anl Profcssion Gxlc): Any City or County which rcquircs a Fmil k) conslruct. alter. impnrvc. dcmtlish or rcpoL any slruclurc, Fior to its issuancc, also rcquircs lhc applicant for such lErmil kr lilc a signcd slatcmnt that hc or shc is liccnsd pursuant to lhc lrovisions of thc Contractor's Liccnscd law (Chaptcr 9, Comrcncing wilh Selion ?000 of Division .1 of lhc Busirc$s and Prolcssions Culc) or that hc or shc is crempt thqcfrom aftl lhc basis for thc allcgcd cxcmption. Any violation of Scction 70.1 L5 by any applicant for a [Ermit subjels thc applicant kr a civil penalty of not morc thun fivc hundrcd dollds ($500). _1, as owtrcr of thc propcrty, or my cnlployccs with wagcs as thcir solc conlpcnsalion, will do thc work and lhc structurc is nol intcndctl or otl'cred lirr salc (Sec.7044, Ilusincss and Prof'cssions Crxlc: Thc Contraclor's Liccnse Law docs not apply to an owncr of thc pn)lrcrty who builds or intpntvcs thcrcon, and who docs such wrlrk lrimscll'or hcrsclf rlr thrlugh his or her owtr cntpkryccs, providcd tlrat strch improvcnrclrts arc mlt intcndcd rlroltcrcd tirr salc. ltl howcvcr, thc huilding or impnrvcment is soltl within otrc year of comphtk)n, thc Owncr lluildcr will havc tlrc hurdcn ol'pmving that hc or shc tlid mrt build or improvc thc proJrcay lbr thc purptrc o[ saic). _1. as()wncrof thc property. amcxclusivclycontracting with liccnsctl contraclors lo collstruct thc prujcct (Scc. 7044. Business arxl hrrtcrision Cotlc: The Contraclor's Liccltsc Law docs not apply to an owner of propcrty who builds or improves thcrcott. and who contracls ftrr such pnljccts with a Glntracto(s) liccnsctl pursuant lo thc Conlraclor's Licensc hw). -IamcxemptundcrScctirln-'B.&P.C.filrlhisrcastllt.f r.. r ,,. WORKERS' CO[\T PENSATION DECLARATION I hcrcby alfirrn undcr Jrcnalty of pcrjury onc of thc lirlklwing declaratiorts: --l havc and will maintain a Ccrtilicatc of Conscnt to Sclf-lnsurc lbr workcrs' conrJrcnsation, as provirlcd firr by Scctitltt 37fi) of the Lahrr C<xlc, lbr thc Jrcrlbrmancc ol'thc work lbr which thc Jrcrmit is issucd. _l havc and will maintain workcrs' comJrcnsation insurancc. as rcquircd by Scct ion 37fi) of thc [:bor Codc, lilr thc Jrcrfirrmancc of thc work lilr which this permit is issucd. My workcrs' compcnsation insurancc carricr arxl Jxllicy numbcr arc: Policy Numbcr: Expircs: _l ccrtity that in thc pcrlormancc ol'thc work lor which this pcrmit is issucd, I shall not cnrploy any pcrson in any manncr so as to hccome subject to thc wurkcrs' comJrcnsation laws of Calililrnia. and agrcc that if I should bccomc suhjcct to thc workcrs' compcnsation provisions of Scction 3700 of thc Latxlr Codc, I shall, torrhwith comply with thosc prrvisions. WARNING: Failurc to sccurc workcrs' comJrcnsation covcraglc is unlawlul, and shall sub.icct an cmploycr to crintinal pcnaltics and civil lincs up to onc hunrlrcrl thousand dollars (S100,Uru), in addition lo lltc cosl of comlrcnsalion. damagcs as providcd lirr thc Scclion 3076 of thc Lahlr Crxlc, intcrcsl antl allorrcy's tbcs. Dete: LICENSED CONTRACTOR DECLARATION I hcrcby allrm under pnalty of Jrcrjury that I am liccnscd undcr provision of Chaptcr 9 (comrncncing with Scction 7UX)) of Division 3 of thc Busincss and Pnlt'cssions Ctilc, and my liccnse is in full torcc and cffcct. l.ice-trsc Nulnbcr: W I hcrcby affrm undq Fnalty of JErjury that thcrc is a @Ntrudion hnding agcrey for the Frfomree of lhc work for which this Ismit is issucd (Scc. 3097, Civ. C.). lxndcr's Nam: lrndcr's Addrcss: APPLICANT DECLARATION I lrcrchy atl-trm undcr pcnalty of pcrjury onc of thc lilllowing dcclaratiorts: Dcrnolition Pcrmits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40, I'art6) _Rcquircd l,cttcr of Notilication _l ccrtity that thc t'cdcralrcgulations rcgarding asbcstos rcmovalarc not applicable to this project. _l ccilify that I havc rcad rhis epplicati(ln drJ starc that thc atNvc inlbrrotiotr is coret. I aerc to @mply with all City atxl Counly ordhanccs and State Laws rchting h huilding c(rnstruction, atxl hcrcby authrrizc rcFc$ntslivcs ofthis City and County to cntq uF)n tlrc rbovc mntioncd prupcrly for inslEction purynscs. Applicsnt or Acent SisDlure: Date:- Pemfle nsme (grinl): Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenVl nsu lation Roof Sheathinq Shear Wall Framing Insu Iation/Energy Drywall Ext./lnt. Lath Brown Coat [\Iasonry Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif tl ,l s,2- FINAL lt lzlTt I >Mr r/ Certificate of Occupancy I Notes, Remarks, Etc Florr nP*n7-2nl q