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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE !D/SIG.COMMENTS OWNER BUTLDER DELCARATTON <br />I hcrchy afltm undcr pcnalty of JErjury that I am cxcmpt lirm thc Contrackns' Liccns liw tor the tbllowitrg rcasrn (Ss.7011.5 <br />Busirrcss aul Prottssirn Codc): Any City or County which rcquircs s Frmit to construct. altcl improvc, dcmrlish or mpair any <br />slruclurc, pri(r lo its issuance, also rcquircs thc applicant tbr such Frmit k) lilc a signcd statcmnt that hc or she Ls liccnscd pursuant <br />to thc ltrovisious of llE Contraclor's Liccnsd Law (Chaplcr 9, Commcncing wilh Scctio[ 70(X) of Division .J of thc Busincss and <br />Pr)fcssions Codc) or th{t hc or shc is cxcmpt thercftom and thc basis tirr thc allcgcd cxcmptiul. Any violation of Sccti(r 70.1 1.5 by any <br />applicanl for a Jrcmit subjsls lhc applicant to a civil pcnally of nol morc th{n fivc hundrcd dou{s ($500), <br />_1, as owner of thc propcrty, or my employees with wagcs as their solc compcnsation, will tlo thc work and thc slructurc is not <br />intcrxlctl or othrcd tor salc (Sc--.7044, Business and Professions Ctxle: Thc Contractor's Liccnsc l.aw docs not apply lo an owncr of <br />thc pnlJrcrty wtxr builds or improvcs thcrcon, arxl who drrcs such work himsclf or hcrsclf or through his or hcr own cmpk)yccs, <br />providcd that such improvcrncnts arc not intenlcd or ollbrcd tbr sah. It, tnwcvcr, thc buikling or impn)vcrcnt is sokJ wilhin onc ycar <br />of complctkln, thc Owncr Builder will have thc burden of proving that hc or shc did not buikl or improvc thc pnrJrcrty lirr thc purprsc ol' <br />salc). <br />_1. as owncr of the propcrty, am exclusively contracting with licenscd contractors to construct thc projcct (Scc. lOM, Busincss <br />anl Pnrtbssion Ctxle: Thc Contractor's Licensc Law does not apply lo an owner of proJrcrty who builds rlr improvcs thcrcon, <br />and who contracts lilr such projccts with a Contractor(s) licenscd pursuant to the C<lntractrlr's Liccnsc Law). <br />-lamexcmptundcrSectitln-,B.&P.C.forthisrcasrrn.Date: Owner: <br />WORKERS' COTIIPENSATION <br />DECLARATION <br />I hcrcby atfirm under pcnalty of Jrerjury one of the tbllowing dcclarations: <br />_l havc and will maintain a Ccrtilicate of Conscnt to Selt'-lnsure firr workcrs' compcnsation, as providcd tirr by Scction .3700 of thc <br />Lahrr Ctx.lc, tilr thc Jrcrlbrmance of thc work for which the Jrcrmit is issucd. <br />E nu," <br />thc work <br />and will maintain workcrs' comJrcnsation insurance, as rcquircd by Scct ion -1700 of the Labor Codc, lirr thc Jrcrlirrmancc of <br />lirr which this pqrmit is issued. My workcrs' compcnsation insurancc carricr and Jxrlicy numbcr arc: <br />otD Nh,qrL <br />vJ c-t t5 ,0.]o zlPolicy <br />_l ccrtity that in thc pcrlirrmancc of thc wrlrk tilr which this pcrmit is issucd, I shall not cnrpkry any pcrs()n itr any manncr <br />and <br />thc <br />LICENSED CONTRACTOR <br />DECI..ARATION <br />I hcrcby allrm untlcr Jrcnalty of pcrjury that I am licensed undcr provision of Chaptcr 9 (commcncing with Scction 7U)()) of Division .] <br />ol' the Busincss and Prol'cssions Codc, and my liccnse is in full tbrcc arx.l eltcct. <br />Liccnsc ct"r*' B Liccnse Number:ltov tto <br />?. 'l-) <br />Contractor:(Z>rrEnA- t.rr {po 6ogJ <br />{W <br />I hcrcby affum urklcr lEnalty of JErjury that thcrc is a custructk n hndinS agcncy for thc lrcrfomncc of lhc vork for which lhls Ismit is <br />issucd (Se. !(x)7, Civ. C.). <br />I-cndcr's Namc: <br />hndcr's Addrcss: <br />APPLICANT DECLARATION <br />I hcrehy allirm undcr pnalty of prjury one of the tbllowing declarations: <br />Dcmolition Pcrnrits-Ashestos Notitication Federal Rcgulations (Title 40, Part6) <br />_Rcquircd lrttcr of Notitication <br />_l ccrtily that thc l'edcral asbcstos rcmovalarc not applicahlc lo this projccl. <br />@."nily tlrat I ltavc rcarl atxrvc intirrmation is corrcct. I agrcc to comply <br />rcprcscntativcs ol' this City <br />with all City and County <br />arrd County to cnlcr uJxln lhcortlinalrccs irnd Statc Laws <br />abovc mcntioncd proJrcrty tilr <br />rtpplicant or Agent <br />Pentritee narrre <br />purF)ses. <br />antl hcrcby authoriz-c <br />o^r". lz. 17.1) <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bf loor/Ve nVl ns u lati on <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />FINAL Rlf-JO Ectt^'€bs "27 <br />Certificate of Occupancv <br />Notes, Rernarks, Etc. <br />Elorr nP.-n7 -2n1q <br />t <br />I <br />I