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BUILDING- INSPECTOR RECORD a <br />SITE-WORK DATE ID/SIG COMMENTS OWNER AUILDER DELCARATION <br />I hcrcby allirrn undcr FEnalty of Frjury that I am cxcmpt from lhc Conlrflclors' Liccn* taw for lhc folktwifigapamn (Sqr1l3l.5 <br />Business and Profcssion Codc): Any City or County shich rcquircs a lumit to @nslrucl. allcr. impmtt. dcmlish "r rfiair any <br />struclurc. prin lo ils issuarcc. alrc rcquircs thc trpplicatrt for such lErmil ft] filc a signcd stutcmnl that hc or shc is licenscd puNuant <br />lo thc provisions of thc Conlraclor's Liccn*d law (Chaplcr 9. Commencing with Scction 7000 of Division 3 of lhc Busincss snd <br />Profcs$ionsCodc)orthuthcorshciscxemptthercfromarrdthcbtrsisforlhcallcgcdcxcmplion. AnyviolalionofsctionT03l.5byany <br />applicant for a fEnnit subjccts thc applicant to a civil pcnrlly of not more thon livc hundrcd dollors ($5U)). <br />I <br />_l.as owncrofthcpn)pcrty.ornlycmployccswithwagcsasthcirsolccompcnsation.rvilldolhcworkandlhcslructureisnot <br />interrded or offcrcd for salc (Scr.7044. Busincss and hot'cssions Codc: The Contractor's Licensc L.aw docs not apply to an owncr of <br />thc propfly who builds or inlprovcs thcrcrln. and who docs such work hirnsclf or hersclf or through his or hcr own cmployecs. <br />providcd that such inrprovcnrcnts arc not intcndccl oroffcrcd ftrr salc. lf. howcvcr. thc building or irnprovcrnenl is sold within one ycar <br />of conrplction. ttrc C)wncr Buildcr will have thc burdcn ol'proving lhat hc or shc did not build or irnprovc thc propcrly for thc purynsc of <br />sah). <br />-t. <br />as owncr ol'thc propcrty. am cxclusivcly conlritctirrg with liccrrscd conlraclors lo construct lhc projcct (Sec. 7(X4. Ilusincss <br />and Pnrlbssion Clodc: Thc Contractor's Licensc Law tlocs nol apply to an owncr of'propcrty who inrproves thercon. <br />and who contracts for such projccts with a licenscd pursuant to the Contractor's <br />_l am excnlpt undcr lhis <br />-t/ <br />I hcrcby afllrnr undcr pcnally of pcrjury onc ol'lhc lbllowing <br />_l havc and will nuintain a Ccrtificatc o[ Conserrt to Sclf-lrrsurc for workcrs' conrJrcnsation. as provided lbr by Scclion 3700 of thc <br />l-atxrr Codc. for thc perform,ancc ol'the work for which thc lrcrrnit is issuctt. <br />_l havc and will maintain workers' compensation insurlncc. .rs rcquircd by Scction 37ffi of thc l,abor Code. for thc pcrformancc of <br />thc work for which this pcrnrit is issucd. My workcrs' compcnsation insurance carricr and plicy numbcr are: <br />Policy Number: Expires: <br />-l <br />ccrlify that in thc pcrlirrrruncc ol'thc work for which this pcrrnit is issucd. I shall not <br />so as to hccomc subjcct to the workers'cornpcnsalion laws of C-'alitbrnia. and agrcc that if I <br />cnrploy any ntanncr <br />thc <br />u'orkcrs' colrtJrclts:rl iort <br />lVARNIN(i: [;ailurc lo <br />provisions of Scction 37fi) of lhc Latxrr lirrthwith <br />sccurc workcrs' comlrcnsation arrd shall pcnallies and <br />civil fincs up to one hundrcd thousand dollars (Sl cost o[as provided for thc <br />i't."and attorrcy's <br />A lhcrcbyaflirmundcrJEmlryofpcrjurythrtlamliensdunderprovishnofChtrplcr9(commrcingwithScclionTo(n)ofDivisionl <br />f.af thc Busincss and Prcfcssions Codc. and my liccn$c is in full force and efTcct. <br />\ <br />License Class: Liccnse Number: <br />11.,r...('onl r:rclor: <br />W <br />I hcrcby affirm undcr Jrcnalty ofpcrjury that thcrc is. conslructhn hnding agcncy for thc pctformncc oflhc work for which lhis Ismil is <br />issucd (Sm. -1097. Civ. C.). <br />Lctttlcr's Nlrttc: <br />lrnder's Addrcss: <br />APPLICANT DECLARATION <br />I trcreby affirm undcr pcnalty of prjury <lne of lhc following dcclaratiotts: <br />Dcmolition Pernrits-Asbcstos Notification Fcdcral Rcgulations ('Iitlc 40. Part6) <br />_Rcquircd Lctter of Nolification <br />_l ccrtify that thc fcderalrcgulations rcgarding asbcstos rcrnovalarc not applicablc <br />-l <br />ccrtily that I havc rcad this applical ahrvc conrply with all City and County <br />orrlinanccs arrd Slatc I-aws rclating <br />ahrvc nrcntioncd propcrty for <br />AJllllicarrl or Agcrrl <br />Pernrilee nanre 7:TT <br />hcrcby <br />ls <br />this City and County to cnter upon the <br />Set Backs I , ltA -1Forms/Stee!/Holdowns Nltlr21 ;r{, r <br />Erection Pads //(7,- 14( <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenVl nsu lation /l A --? <br />Roof Sheathinq ///6//V rl/autu ,Im 6OL <br />Shear Wall ////t//c frU.Z-rr-,nzy't8W <br />Framing illru/tu/?c@J*2,,-4 <br />'b2 <br />lnsulation/E EW <br />Drywall a I <br />&iltnt. Lath <br />Brown Coat <br />Nlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif . <br />t/A AT <br />FINAL /vlylfr?llhn[/a Ylfikl <br />Certificate of Occupancy , <br />,I <br />Etc. <br />/ +bn!k/,L?-K <br />\--,2 /I <br />f <br />I <br />I <br />I <br />I <br />I