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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby aflirm undcr lEnalty of lErjury that I am cxcmpt from lhc G)nlraclr)s' Liccnsc Law for the following rcasrn (Scc.70Jl.5 <br />llusircss aftl Prolbssiou C<xlc): Atry City or Coutrty which rcquircs a lsmit k, q)nstrucl. altcr. improvc. dcmoli$h or rcIair any <br />strucluc. Fior to its issuancc. also rcquircs thc applicant tbr such Frmil k) tilc a signcd stalcmnt that hc or shc is liccn$d pursuant <br />to lhc pn)visions of lhc Contrsck)r's Liccnscd [2w (Chaptcr 9, Commncing sith Scction ?U)0 of DivisioD 3 of thc Busincss and <br />Pmfcssi(rns Cfilc) or that lrc or shc is cxcmpt thcrcli(rnr .[d thc hdsis for lhc allcgcd cxcmpti(tn. Any violation of Sccti(il 70] I .5 by any <br />applicant li)r a JErmil suh.i(ts Ihc applicanl k, a civil pcnalty of nol morc than fivc hundrcd dollds ($500). <br />_1, as owncr of thc propcrly, or my cmployccs with wagcs as thcir solc conlpcnsalion, will do thc work and thc struclurc is not <br />intcrxletl or ofl'ercd lilr salc (Sc.c.7M4. Busincss and Prol'essions Crxle: Thc Contractor's Liccttsc Law docs not apply to an tlwncr of <br />thc pnrl--r1y who huilds or inrpr)vcs tlrcrcrrn, antl who tftrcs such work himsclf rlr hcrsclf or thnlugh his or hcr own cmployccs, <br />prlvidcd that such inrprovcu**nts arc not intcndcd orollbrcd tirr salc. It, lnrwevcr, thc building rtr improverncnt is sold withinonc yc:u <br />o[comphtion, thc Owncr Buildcr will havc thc burden of proving that hc or shc dirl rxlt buill or improve thc progrrty lilr thc pur;xts;c o[ <br />sah). <br />_1, asowncrof thc propcrty. amcxclusivelycontracting with liccnscdcontractomtocottstntct thc pntjcct (Scc.7044, Busincss <br />antl Pnrtcssrlr Codc: Thc Contractor's Licensc Law tlocs not apply to an owncr ttf proJrcrty who builds or improvcs thcrctln, <br />anrl who colltracts lilr such pro.jccts with a Contractor(s) liccnscd pursuant to thc Contraclor's Liccnsc Law). <br />-l <br />am cxcmpt undcr Section-, B. & P.C. for this reason. <br />Owner: <br />wonrgRs' col\tPENS <br />DECLARATION <br />I hcrchy al'l'irm undcr pcnalty of Jrcrjury one of thc tolkrwing dcclarations: <br />_l havc arrrl will maintain a Ccrtillcatc of Conscnt to Scll'-lnsurc lilr wrlrkcrs' comJrcnsation, as pnrvidcd litr hy Scction 37fi) of thc <br />[.alxrr Crxlc, lilr thc Jrcrlirrmancc of thc work lirr which thc pcrnrit is issucd. <br />_l havc and will maintain workcrs' cunrJrcnsation insurancc, as rcquircd by Scctirttt 37fi) of thc Lahor C<xlc. lirr thc lrcrtilrnrancc of <br />thc wtrrk lilr which this Jrcrnrit is issucd. My wrlrkcrs' com[rcnsalion insurancc carricr and Jxrlicy numbcr arc: <br />Policy Numbcr: Expires: <br />_l ccrtity that in thc;rcrftrrmancc of thc work tirr which this Jrcrmit is issucd, I shall not cntploy any lrcrson in any manncr <br />so as to hccomc subjcct to thc workcrs' compcnsation laws of Calitirrnia, and agrcc that if I shruld bccomc subjcct to thc <br />workcrs' com;rcnsation provisions ol'scction .1700 of thc Latxrr Crxlc, I shall, fbrthwith comply with thrlsc provisirlns. <br />WARNING: Failurc to securc w<lrkcrs' comJrcnsation coveragc is unlawlul, and shall suhjcct an employcr to criminal Jrcnaltics and <br />civil tincs up to onc hundrctl thousand dollars (S100.Uru), in addition to thc cost of compcnsalion, damagcs as providcd lilr the <br />Scction 3076 of thc Labor Gxlc, furtcrcst and attrlrncy's l'ccs. <br />LICENSED CONTIUCTOR <br />DECLARATION <br />I hcreby atlrnr undcr Jrcnalty of pcrjury that I am liccnrcrl undcr provision of Chaptcr 9 (comrncncing with Sccti<rn 7firu) of Division 3 <br />of lhe Busincss and Prol'cssions Codc, and my licensc is in full lilrce and cltect. <br />Liccnse Class: Licensc Nunthcr: <br />Contractor: <br />CONSTRUCTION LENDING AGENCY <br />I hcrcby allirm undcr lEnalty of Jrrjury that thcrc is a construclirn bnding agcncy lbr thc lErftrmrec of lhc work for which this Jsmit is <br />issucd (SN. .1097, Civ. C.). <br />[rndcr's Nanrc: <br />APPLICANT DECLARATION <br />I lrcrehy allirnr undcr pcnalty of pcrjury onc ol'thc firllowing declaratirtns: <br />Dcmolition Pcrmits-Asbcstos Notilication Fctlcral Rcgulations (Titlc 40. Pan6) <br />_Rcqu ircd lrttcr of Notilication <br />_l ccrrity lhal thc fcdcral rcgulations rcgurling ashcsl(rs rcm)val arc nol applicahlc to lhis pmjcct. <br />_l certifi thar I havc rcad this applicarion anl statc thol lhc atnvc infomslion is coEet. I .lre to crtmply with all City.nd County <br />oRli[anccs and Statc llws rclating lo huilding construction, atr, hcrcby aullxrrizc rclrcrcntativcs ofthis City and County to cntq uF)tr thc <br />atDvc mcntioncd p()[Erly lbr inslBctiotr puqbss. <br />Applicant or Agent Signature: <br />Penrritee nanle I rrri rrl l: <br />l)ale: <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bf loor/VenUl ns u lation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />Insulation/Enerqy <br />Drvwall <br />Ext./lnt. Lath <br />Brown Coat <br />[\/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif. <br />,ll cI .l -tl -t <br />FINAL I {/w pffI-fz / <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />Flav n9,-n7 -2n I q