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BUILDING. INSPECTOR RECORD
<br />SITE.WORK DATE ID/{iIG.COMMENTS OWNER BUILDER DELCARATION
<br />I hcrcby alllm uilcr lrcMlly of JErjury thd I am cxcmJrl from thc ContrackrN' Liccn$c [f,w for the toltrwittg rc{stn (Scc.70-] 15
<br />llusmess aNl Protbssbn C(rlc): Atry Cily or County uhich rcquircs a ;rrmit kr consruct. altcr. improvc. dcmtlish or rcpair 8ny
<br />structrrc. prior k' i(s issuuncc, also rcquires lhc apllicant lbr such lrcmil b filc a signcd slatcmcnt that hc or shc is licensd pursuant
<br />t(, thc ln)vision$ of thc Conlrackf's Liccnscd hw (Chaplcr 9, Conrmcrchrg with Sh-tion 70(X, of Division 3 of thc Busincss anrl
<br />P()tbssionsCodc)orthathcorshciscxcmptthcrcftomandthcbasisfortheallc8cdcxempti(rn, Anyvi(rldtionofSetitmT0]l.5byrny
<br />applicatrt lirr a JEmit subjccts thc applicant k, a civil pcnrlty of not morc than livc hundrcd dollus ($500).
<br />_1, as owrrcr ot'thc propcrty, or my cmployccs with wagcs as lhcir sole compcnsation. will do thc work alxl thc structure is nol
<br />intcrxlcd 6r oll'cretl lirr sale (Sec.7044. Busincss and P()l'cssions C<xlc: The Contraclor's l-icensc Law drlcs not apply lo an owner of
<br />thc pnrpcrty who huilds ()r improvcs thcrcon, and who drrcs such work himsclf rtr ltcrsclf or through his or hcr own cmpk)yces,
<br />providcd that such imprcvcrncnts arc rxrt interxlcd rlr olfcrcd lirr sah. If. howcver, thc huilding or improvemcnt is srtkl within one ycar
<br />ol'contplction, thc Owncr Buildcr willhavc thc burdcnof pft)ving that hc or shc ditl not buikl or improvc thc properry litr lhc purJxlscof
<br />salc).
<br />_1, as owncr ol'thc propcrty, aln cxclusivcly contracting with liccnscd contractors to construct thc projcct (Scc. 7U4, Busincss
<br />and Prulbssion Corlc: Thc Contractor's Liccnsc Law docs not apply to an owncr of propcrty who builds or imprtlvcs thcreon,
<br />and who contracts klr such projccts with a Contractor(s) liccnscd pursuant to thc Contractor's Liccnsc Law).
<br />-l
<br />am cxempt undcr Scction-. B. & P.C. for this rcasott.
<br />Owner:
<br />wonrgRs' colttPENS
<br />DECLARATTON
<br />I hcrchy all'irm undcr J--nalty ol'1^-rjury onc ol'thc lillklwing dcclaratiotts:
<br />_l havc arxl will maintain a Certilicatc of Conscnt to Scll'-lnsurc filr workcrs' comJrcnsation, as pnrvidcd tbr by Scction 37fi) of thc
<br />Lahrr Crxlc, lilr thc Jrcrfirrnrancc of thc work lor which thc Jrcrmit is issucd.
<br />_l havc and will maintain workcrs' compensation insurancc, as rcquircd by Scction J700 of thc [:bor Codc. litr lhc Jrertilrmancc tlf
<br />thc work lbr which this prmit is issucd. My workers' compcnsation insurancc carricr aml Jnlicy numbcr arc:
<br />.",rr.r. Slct*e CcrU P.
<br />Policy r.rrrnt"r' Q 15 Q262 Expires:X -l(t'- ''^ I
<br />_l ccrtily tlrat in the pcrftlrnrancc ol'thc work lirr which this Jrcrnrit is issucd, I shall nrtt cmploy any lrcrson in any manncr
<br />so as to bcconrc subjc-ct to thc workcrs' conrpcnsation laws of Califirrnia, and agrcc that if I should bccomc subjcct to lhc
<br />workcrs' cornJrcnsation provisions of Scction .i700 of thc Lahrr Codc. I shall, lbrthwith comply with thosc prtlvisittns.
<br />WARNING: Failurc t() sccurc wrlrkcrs'conryrcnsation covcragc is unlawltl, anrJ shall suhjcct an cmpklyer to criminal Jrcnaltics and
<br />civil lincs up to ol'lc- hundrcd thousand dollars ($100,fin), in atldition lrt lhe cost of comJrcnsation, danragcs as providcd tilr the
<br />Scction .)076 of thc Lahlr Codc, intcrcst and atlorncy's l'ccs.:z --l!^--.-
<br />LTCENSED CONTRACTOR
<br />DECLARATION
<br />I hcrcby allrm untlcr pcnalty of Jrcrjury that I anr liccnscd undcr pnlvision of Chaptcr 9 (commcncing with Section 7UX)) of Division 3
<br />ol' thc Busincss and Prol'cssions Codc, and my liccnsc is in tull lirrcc arxl cll'cct.
<br />Liccnse cror., ( - -)9 Liccnse Number:
<br />o*", \l -75- 2c,7t>
<br />W
<br />I hcrcby allirm undcr pMlty of Jrcrjury that thcrc is a c\rnslructi(rn lcnding agcncy for thc Jrcrformrec of thc work fitr which l:,is lErmit i\
<br />issucd (Scc. .1097, Civ. C.).
<br />[,cndcr's Name:
<br />Ixndcr's Address:
<br />APPLICANT DECLARATION
<br />I hcrcby afl'rm urrdcr Jrcnalty of pcrjury onc of thc tillklwing dcclaratiuns:
<br />Dcnxrlition Pcrmits-Ashstos Notification Fcdcral Rcgulations (Titlc 40, Part6)
<br />_Rcquircd lrtter of Notilication
<br />-l
<br />ccrtily thal lhc l'cdcral rcgulations rcgsnling astrstos rcmrval arc not spplicablc to this pmjcct.
<br />_l ccrtity thar I havc rcad this appli{arion anl statc thil thc trix)vc informti(,n is cor(t. I aere k, comply with all Cily an'l Counly
<br />ordinanccs und Statc Ltws rclating k, building constructio[ onl hcreby aullnrizc rcltrcsnlativcs ofthis City ed County b cnt6 uF)n thc
<br />abovc nrcntioncd prlJrcrty lirr insJrcction purlx)scs,
<br />Applicant or Agent
<br />Penttitee nanre
<br />oarc, \l -% - z.>2o
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />S u bf loor/Ve nVl nsu I atio n
<br />Roof Sheathing I ),&*Y(
<br />Shear Wall /
<br />Framinq
<br />lnsu lation/Enerqy
<br />Drvwall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputv Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />I t
<br />4,AI
<br />FINAL t to tryilLfl ,t {0
<br />Certificate of Occupancv I t'
<br />NoteS, Eemarks, Etc I -ra
<br />l,Llwl'7"1 Ln-(Ou .Y-T
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<br />Flav n9,-n7 -2n 1 q
<br />r)qro. \l '?<' ?-A-u
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