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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcrchy aflirm undcr lrcmlty of Frjury that I am cxcmpt ltom llE G)nlrackrs' Licensc [:w for lhc following rcawn (S4.70J1.5 <br />Busincss arxl Prolbssion CrxJc): Any City or County shich rcquircs a lrcrmit k, construcl. altcr. intprove. &molish or rcluir any <br />structurc, ltrbr lo its issuancc, also rcquircs thc applicatrt lbr such JErmit to l'ilc a si8ncd statcmnt thal hc or slrc is licen*d pursuant <br />to thc pmvisions of tlrc Contractor's Liccn$cd Lav (Chaptcr 9. Commcre-ing silh SNIhn 70fl) of Division .l of lhc Busircss and <br />Pnrfcssfuns Codc) or thar lrc or she is cxctrrpt thcrcliom and thc hasls tirr lhc allcgcd cxcmplion. Any violrtktn of ScctiM 7O.l1.5 by any <br />upplicant lilr r pcrmit subjsts thc applicatrt k, a civil pcnally of not morc thaD fivc hu[drcd dollars ($500). <br />_1, as owncr of thc propcrty, or my cmployccs with wagcs as thcir solc com[rcnsation, willdo thc work and the slructurc is not <br />iltelxled oroll'ercdtbrsalc(Sec.7(X4,BusincssanrlProt'cssionsCtxlc:ThcContract()r'sLicenseLtwdocsnotaPplytoanowncrof <br />the propcrty who btrilds or improvcs thcrcon, and wlro drrcs such work himsclf or hcrsclf or thn)ugh his or hcr tlwn cmployccs, <br />providcd that such irnprovcmctrts arc not fultctxlcd or otlbrcd lilr sah. It, txlwcvcr, thc building or imp()vcmcnt is sold within onc ycar <br />ol'complction, thc Owncr Buiklcr will havc tlrc burden ol'proving that hc or shc did not build or inrprove thc propcrty lilr tlrc purprse ol' <br />sah). <br />_1, as owtrcr of tlrc propcr"ty. am cxclusivcly contracting with liccnscd contractors to constnlct thc pntjcct (Sec. 7U4, Busiltess <br />antl thrtbssion Cotle: Thc Contractor's Liccnsc Law docs not apply to an owncr of proJrcrty who huilds rlr improves lhcreon, <br />and who contracts ltrr such projccts with a Contractor(s) liccnscrl pursuant to thc Contractor's Liccnsc Law). <br />_l anr cxc'mpt .C. lirr lhisvl7,-1 <br />t)ti('t.Att^'l'loN <br />I hcrchy alf irm undcr pcnalty of Jrcrjury onc ot'thc lillkrwirtg dcclaratiotts: <br />_l havc and will maintain a Ccrtilicatc of Conscnt to Sclt-lnsurc fbr workers' comJrcnsation, as providcd titr by Scctitln 3700 of thc <br />Latxlr Crxlc, lor thc pcrltrrmancc ol'thc work tilr which thc Jrcrmit is issucd. <br />_l have and will maintain workcrs' contJrcnsation insurancc. as rcquircd by Scction .1700 of thc Lahor Crilc, tor thc Jrcrlitrmancc o[ <br />thc work lor which this pcrmit is issucd. My workers' compcnsation insurancc carricr arxl pllicy numbcr arc: <br />€Policy Numbcr: Expircs: <br />_l ccrtity that in thc pcrlilrmancc ol'tlrc work lirr which this Jrcrmit is issucd, I shall not cntpkly any pcrson ilt any manncr <br />so as to becorrrc subjcct to thc workcrs' comJrcnsation laws of Calilirrrria, and agrcc that if I should bccomctuhjcct ttl lltc <br />workcrs' comJrcnsation prcvisions of Scction 3700 of thc l-ahrr Codc, I shall, lirrthwith comply with thosc prrlvisions. <br />WARNING: Failurc to sccurc workcrs'conrpcnsation covcragc is unlawful, and shall cmploycr to crinrinal pcnaltics and <br />civil lincs up to one hundrerJ lhousand dollars irr atldition to thc cost rtl'damagcs as providcd tilr thc <br />Scction 3076 ol'thc Latxrr CuIc, intcrcst and <br />I hcrcby allirm undcr pcnalty ot'J^-rjury that I anr liccnscrl undcr provisilln of Chaptcr <br />of thc Busincss and Prolbssions Codc, and my liccnsc is in l'ull lirrcc anrl cfl'cct. <br />(commcncirrg 7firu) of Division J <br />Liccnsc Numbcr: <br />f \...^. <br />W <br />I hcrcby alfum undcr Fnalty of JErjury that tlsc i$ a constructhn lcnding agcrey tbr thc Fstbmancc of thc work for uhich this JEmit is <br />issucd (Ss. .1097, Civ. C.). <br />kn,lcr's Namc: <br />APPLICANT DECLARATION <br />I lrcrcby allirm undcr grcnalty of Jrerjury onc of thc lirlklwing dcclarations: <br />Delnolit ion Pcrmit s-Asr^kstos Nol ificat ion FcrJcra l Regu lat ions (Tit lc 40, Part6) <br />_Rcquired lrttcr of Notilicatktn <br />_l ccrtily that thc l'cdcral regulations regarding asbcstos rcnxrval arc not applicahlc to lhis pnrjcct. <br />_l ccrtily that I havc read this application and statc that thc atxrvc intirrmation is corrcct. I agrcc to comply with all City anrl County <br />rlrdinaft6es and Statc Laws rclating herehy authorize <br />atxrvc mcntioncd proJrcrty lor <br />Applicanl or <br />Penrritee nanre <br />constntcl <br />rva o <br />rcprcsentalivcs of this City and County to cntcr uJxtn thc <br />\ J,/q/Lo <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bf loor/VenVl nsu lation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsu lation/Energy <br />Drvwall <br />Ext./lnt. Lath <br />Brown Coat <br />N/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif .t <br />7rn/tnrF'tlnlxt iW <br />(J , <br />FINAL rxtoyx))WuMq 260 <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />Flarr n9.fi7 -2n 1 6 <br />t j@ub6