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)t BUILDING- !NSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BT,rILDER DELCARATION <br />I hcrcby affrrn undcr Fnalty of perjury ihat I m cxcr{,t frcm the Contmcton' Liccns [:w fo] thc followirg r@sn.(Sec.7031.5 | <br />Busincss ord Pmf6sion Codc): Any City or County which rcquircs a fmil to constrcl. alte, improve, dcmlish or rcpair my <br />stluturc. priT lo ils issumc, also rcquircs thc spplicanl for such lErmil k, filc I signcd statemnt that hc or drc is licensd pusuill <br />to the povisions of thc Contractor's Lhcnrcd trw (Chaptcr 9. Commrcing with Setion 7000 of Division 3 of the Busircss od <br />Prcfcssbns Code) or that he or shc is excmpt llwfrcm ad thc basis for lhc allcgcd cxemption. Any violotion of Setion 703 I .5 by my <br />applicanl for a pcrmit subjsts the applicant to I civil pculty of not mrc thn fivc hundred dollas ($Sfi)). <br />_1. as owncr of the propcfiy, or my ctnployccs with wagcs as thcir sole compcnsalion. will do the work and ttrc structure is not <br />intended or ol'fercd for salc (Sc.c.7o4a, Busincss and Professions Code: The Contraclor's License law does nol apply to an owner of <br />the proJrcrty who bnrilds or improves thercrln and who does such work hirnself or hcrself or through his or her own employecs. <br />providcd that such impovcnrcnts arc not intcrxlcd oroffcrcd for sale. If, howercr. thc b,uilding or irprovcnrnl is sold within onc )ryu <br />of completio[ thc Owncr Buiher will have tlrc burdcn of proving that hc or she did not buih or improvc thc property for thc purpsc of <br />sale). <br />_1. asownerof thc propcny, amexclusivelycontracting with licenscd conlractors to construct thc projcct (Sec. 7044, Busincss <br />and Profcssion Codc: Thc Contractor's Liccnsc Law does not apply lo an owncr <lf prolrcrty who builds or inrprovcs lhcreon, <br />and who c<lntrucls for such projccts with a Glntractor(s) liccnscd pursuant to thc Conlractor's Liccnse Law). <br />-l <br />am exempt under Section-. B. & P.C. for this reason. <br />Date:_Ilunor. <br />WORKERS' COMPENSATION <br />DECLARATION <br />I hcreby affirm undcr pcnalty of perjury onc of thc following dcclarations: <br />_lhavcandwill maintainaCertificateofConscnttoSelf-lnsurcforworkcrs'compcnsation,as providedforbyScction3T00ofthe <br />Labor Codc, for the pcrformance of thc work for which thc pcrmit is issued. <br />_l have and will maintain workers' Section 3700 of the l-abor Codc, for the performance of <br />thc work for which this pcrmit is issucd.workers'carricr and plicy numbcr arc: <br />Policy <br />_l ccrrify that in thc Jrerformance of thc work for which this 5rcrmit is issucd. I shall not employ any pcrson in any trurnner <br />so as lo bcconrc subjcct to thc workcrs' compcnsati<ln laws of California, and agrcc that if I should bcconrc subjccl to thc tD <br />workcrs' compcnsation provisions of Section 3700 of thc labor Code, I shall, Ibrthwith comply with thosc provisions. <br />WARNING: Failurc lo sccurc workers' <br />civil fines up lo orrc hundrcd thousand <br />coverage is unlawful. and shall subject an cmploycr pcnaltics and <br />($in addition to lhe cost of as providcd for thc <br />aScction 3076 of thc Latnr Code. intercst and attonrcy's <br />D,'", /7/// / zd <br />DECI.ARATION <br />I hcrcby affirm undcr penalty of pcrjury that I arrr liccnscd under provision of Chaptcr 9 (comnrencing with Section 7000) of Division 3 <br />of the Business and Professions Code. and rny liccnse is in full force and effcct. <br />t) <br />Licensc Nurnbcr: <br />I hercby affEm urder Fnslty of perjury thar therc i$ a construclk n lcnding agcrcy for rhc perfome of thc work for which this pqmit is <br />isrued (Se. 3097, Civ. C.). <br />lrndcr's Nam: <br />lrnder's Address: <br />APPLICANT DECLARATION <br />I My affrnn undcr pnalty of pcrjury one of the following declarations: <br />Dcmolition Pcrmits-Asbcstos Notification Fcdcral Rcgulations (Title 40. Part6) <br />-Rcquircd <br />lrttcr of Notifrcation <br />_l ccrtily that thc fcdcral regulations rcgarding asbestos rcmovalare nol applicablc to this project. <br />-l <br />cenify that I have rcad this application and statc that the atnvc infornurtion <br />ordmanccs and State taws rclating to building construction and <br />above nrntioncd proprty for <br />Applicant or Agent <br />Permitee nanre <br />/t <br />thc <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bf Ioor/VenUI ns u lat io n <br />Roof Sheathino <br />Shear Wall <br />Framinq <br />Insulation/Enerqy <br />Drvwall <br />Ext./!nt. Lath <br />Brown Coat <br />[t/asonrv <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputv Final Report <br />Enqineer Final Report <br />Flood Zone Certif . <br />T@.N\TE v1t1ttu WfUlha<'r9{v <br />I <br />FINAL tdtltN Dbaord ,Ifi:d <br />Certificate of Occupancv I <br />Notes, Remarks, Etc. <br />Rev. 08-07-201 5 <br />I