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BUILDING. INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcreby lfftrm undcr pcnalty of pcrjury that I m cxempt ftom thc Contraclors' Liccns kw for the following rco$n (Scc.7031.5 <br />Busincss srd Prcfcssion Codc): Any City or County which rcquircs I Fmit lo constmt, alts, improve, dcmlish or ElEir uy <br />slructurc, prio to its issuucc. also rcquircs thc applicant for such ,rcrmit to fih a signcd stalcmnl that hc or shc is liccnsd pursuot <br />to thc prcvisions of the Contractor's Licrtrsd tiw (Chrytcr 9. Comncing with Setion 7fi)0 of Division 3 of lhc Busircss od <br />Profcs$ions Crdc) or that hc or she is excmpt thscfrom ard thc basis for thc allcged cxcmption. Atry violation of Setbn 703 I .5 by my <br />upplicunt for a Frmit subj$ts thc applicant to . civil pcmlty of not mrc thil fivc hundrcd dollus ($500). <br />_1. as owrrcr ol'lhe propcrty. or my enrpk)yccs with wagcs as thcir rclc comJrcnsation. willdo the work and the structurc is not <br />intcrrdcd or oflcred for sale (Scc.7(X4. Business and Profcssions Codc: Thc Contractor's Licensc law docs not apply to an owncr of <br />thc pnrJrcrty who builds or inlproves thcrcon. and who docs such work hirnsclf or hersclf or through his or hcr own employecs. <br />providcd that such irnprovcmcnts arc not intendcd oroffcrcd for salc. lf, howclrr. thc building or irrqrnrvennnt is sokl within one year <br />of complction. tlrc Owner Buildcr will have thc trurdcn of proving that hc or shc did not buikl or irnprovc the propcrty for thc puryxrsc of <br />salc). <br />_1, asowncrof thc property, amcxclusivclycontracting with liccnsed contraclorslo construct thc project (Sec. 7014, Busirrcss <br />and Profcssion Codc: Thc Contractor's Liccnse Law does n<ll apply to an owncr of propcrty who builds or improves lherctrn. <br />and who contracts for such pojccts with a Contractor(s) licensed pursuant to thc Contractor's License Law). <br />-lamexemptundcrSc.ction-.B'&P.C.tbrthLsreason.I)tte:Ormer: -wonrgRs'c() <br />DECLARATION <br />I hcrcby affirm undcr pcnalty of pcrjury onc of thc following dcrclurations: <br />_l have and will maintain a Ccrtificate of Consent to Sclf-lnsurc for workcrs' compcnsation. as povided for by Scction 3700 of the <br />Labor Codc, for the pedornunce of thc work for which the permit ls issucd. <br />_l have and will maintain workcrs' compcnsation insurarrce. as rcquircd by Section 3700 of thc Labor Code. for the pcrformarrce of <br />thc work for which this permit is issucd. My workers' compcnsation insurance carrier and p,olicy numbcr are: <br />Policv Numbcr: Expircs: <br />_l certify thal in the pcrfornurrce of thc work for which this Jrernrit is issucd, I shall not cmploy any person in any rnanncr ' <br />so as to bccome subjcct to thc workcrs' compensation laws of California. and agrcc that if I should bcconrc subjcct to thc <br />workcrs' compcnsation provisions of Section 3700 of thc [:bor Ccxle. I shall. forthwith comply with thosc provisions. <br />WARNING: Failurc to sccurc workers' compcnsation covcrage is unlawful. and shall subjcct an employer to criminal penalties and <br />civil fincs up one hundrcd thousand dollars ($100.000), in lhc cost <br />Scction thc Codc, interest and attorncy's fees. <br />\ <br />I lrcrcby afl'irrn undcr pcnalty of pcrjury that I arn liccnscd 9 (comrncncing with Section 7000) of Division 3 <br />of thc Busincss and Prot'cssions Codc, arxl rny liccnsc is in t'ull forcc and cf'fcct. <br />Liccnsc B ZC <br />c <br />W <br />I hcrcby affm undcr Fmlty of Frjury thar thcrc is a snstruction lcnding agcrcy for lhc pcrforme of thc work for which this pcmil is <br />issucd (Sec. 3097, Civ. C.). <br />lrndcr's Nam: <br />lrndcr's Address: <br />APPLICANT DECI ARATION <br />I trcrcby affrnn undcr pcnalty of Jrcrjury onc of the folklwing declarations: <br />Denrolition Pcrmits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40. Part6) <br />-Rcqu <br />ired lrttcr of Notification <br />_l ccrtify that thc fcdcral rcgulations rcgarding ashcstos rcnnvalarc not applicablc to this projc'ct. <br />-l <br />ccrtify that I have rcad this application and statc that all City and Counly <br />ordinanccs and Statc [:ws rclating to <br />abovc nrcntioncd property for inspection <br />,\pplicant or Agent <br />Iternritt'e nttnle <br />zCL tcZ- <br />lo cnter uprn lhc <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenVl nsu latio n <br />Roof Sheathing <br />Shear Wall .1, <br />Framing /2-L/'A re2 rl <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat lvtof.-v lLc Z4 <br />Jtlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Enoineer Fina! Report <br />Flood Zone Certif <br />.t <br />FINAL /uftrdo LO,,N*AE ryV <br />Certificate of Occupancy J <br />Notes, Remarks, Etc <br />Rev. 08-07-201 5