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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcrcby atfum undcr lrcnally of Frjury lhnt I am crcmpl h('m thc Grntrack)N' Liccns Las lirr thc folkrwing rcavrn (Soc.7O-11.5 Business aul Prolcssion Gxlc): Atry City or County which rcquircs a lErmit to c(rnstruct. allcr. improvc. demolish or rcpat any slructurc, pdor to ils issuancc, dm rcquircs thc applicanl for such lrcmit k, lilc a sigrcd slalcmnt lhat hc or slE ic liccnsd puBuanl to tlre pft)visiurs of thc Grntract(r's Liccnsd llw (Ch{ptcr 9, (ommcncirg with Sccti(rn 7000 of Divisiotr .J (rf thc Businc$s and P()lbssr)nsG)dc)orlhathcorshciscxcmptlhcrclirmandthcbasisforthcallcgcdcrcmption. Anyviolati(rnofSctbnTO3l.5byany applicant t(,r a lrermit subjccts lhc applicant to a civil pcnalty of trol morc than live hundrcd dollars (S5(x)). _1, as owncr of lhc propcrty, or my cmployccs with wagcs as thcir solc compcnsation. willdo thc work and thc str'.&*lurc is not intcldcd or oll'crcd lirr salc' (Scc.7044, Busincss arrd Pnrl'cssions Crxlc: Tltc Cortlractor's Liccttsc l-aw drrcs not apply to an owncr of thc pn)pcrty wlxl huikls or impr()vcs llrcrc.on. aml wlxr tl<rcs such work himsclf or hcrsclf or thr()ugh his rtr hcr ttwlt cmployccs, providcd that such improvcrncnls arc mrt intcndcd or oll'crcd tilr salc. Il, howcvcr. thc huilding ()r improvcrncnt is soltl within onc yc'iu ol'complction, tlrc Owncr Builder will havc thc hurrlcn ol'proving that lrc rlr shc did mrt buikJ or intprovc thc propcrty lbr thc purJxlsc ol' p , asowncrof thc profL-rty, amcxclusivclycontracting with liccnscd conlractorstoconslruct thc projcct (Scc. 7U4, Busincss Pnrlbssirn Ctxlc: Thc Contractor's Licensc Law rloes not apply lo an owncr of proJrcrty who huilds or improvcs thcrcon. who conlracts for such projects with a Contractor(s) liccnscd pursuant to thc Contractor's Liccnsc Law).and _l anr cxcnrpt B.tirr this rcason. I hcrcby alf irm undcr pcnalty ol'pcr.iury onc of thc lirllowing _l havc and will maintain a Ccrtiticatc of Consent to Sclt'-lnsurc tirr workcrs' comgrcrtsation, as providcd filr by Sccti<ln 1700 of thc l.atxlr Crxlc, lor thc Jrcrfilrmancc of thc work tirr which thc Jrcrnrit is issucd. _l havc and will maintain workcrs' comJrcnsation insurancc, as rcquircd by Scction .17ffi ol'thc Labor Codc, l<lr thc Jrcrlirrmancc of thc work lilr which this ;rcrnrit is issucd. My workcrs' cornpcnsation insurancc carricr antl Jxrlicy nunrbcr are: Policy Numbcr: Expires: , & f ."nif y that in thc ;rcrlirrmancc ol'the work lirr which this pcrmit is issucrl. I shall not crnpkry any lrcrson in any tnanncr F,-, to bccomc suhjcct to the workers'comJrcnsalion laws of Calitirrnia, antl agrcc thal if I should hccomc subicct to the workcrs' comJrcnsation pnlvisions of Scction .17(X) of thc Lahrr Gxlc, I shall, tilrthwith comply with thosc provisions. WARNING: Failurc lo sccurc workcrs' compcnsation covcragc civil lincs up to onc hundred thousantl dollars ($100.ffi0), in is unlawlirl, antl shall suh.icct an cmploycr lo criminal pcnaltics and kr thc cost of conrlrcnsation, dantagcs as providcd lirr thc Scction J076 thc Ctxle. intcrcst anrl attorncy's l'ccs. o I hcrcby allirnr undcr pcnalty ol'pcrjury that I am liccnscd undcr 9 (commcncing with Scctiott 7m0) ol'Division 3 of thc Busincss and Prol'cssions Codc. arxl my licensc is in tull tirrcc arxl clfbcl. Liccrtsc Nunrhcr: Dale: W I hcrcby allirn utrdcr IEMlly of lErjury thal thcrc is a coDstructt)n htuling agcDcy lilr thc lrcrli)rmncc of thc work fitr which this tsmil ir issue'd (Scc. 1097, Civ. C.). kndcr's Name: Lcntlcr's Addrcss: APPLICANT DECLARATION I hcrctry all-rm undcr Jrcnalty of Jrcrjury onc of thc lilllowing dcclarations: Dcmolition Permits-Astcstos Notification Fcderal Rcgulations (Titlc 40, Part6) _Rcqu ircd lrttcr of Notilical ion _l ccrtily that thc tbdcral rcgulations regarding asbcstos rcmovalarc nol applicablc to this pnljccl. statc that thc- ahrvc inlirrnution is corrcct. I agrcc to comply reprcscntativcs of this City with all City and County atxrvc mcntiorrcd pro1rcrty lilr inspcction Applicant or Agenl Penrritec nanle conslruction, and hcrchy authorizc and o uJxrn tlrc Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Subf lo orlV ent/lnsulation Roof Sheathinq Shear Wall Framinq Insu Iation/Enerqy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif . . ' FINAL l2-ll4*7,02 vWst) Certificate of Occupancy l\-/ Notes, Remarks, Etc. -2fi1