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BUILDING- INSPECTOR RECORD ID/SIG.COMMENTSSITE-WORK DATE Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loo r/Ve nVI n su latio n Roof Sheathinq Shear Wall Framing lnsulation/Eneroy Drywall Ext./lnt. Lath Brown Coat [\Iasonry Pool Fence T-Bar Handicap Req. Deputv Final Report Engineer Final Report Flood Zone Certif r\, FINAL U,\tf \1o Dk#b7 Certificate of Occupancv Notes, Remarks, Etc. ( )\1/N I,lR B t r I t.t )l.tt I hcreby affirnr under penalty of perjury that I anr exempt fronr the Contraclon' l-icense Law for the following reason (Sec'.7031.5 Business and Prol'cssion Codc): Any City or County which rcquircs a p-rrnit lo construct, alter. irnprovc. dcrnolish or rcpair any stntclure, prior to its issuarrce. also requires the applicunt lirr such prmit lo file a signed slatetnent ttrat lre or she ls licensed pursuant to thc pnrvisions ol' thc. Conlractor's l.iccn.scd l,:rw (Chaptcr 9. Cornrncncing with .Section 7(XX) ol' l)ivision J ol'the Busincss and Prol'essionsCrxle)orthatheorsheisexempltherc.tionrandtlrebasistirrtlreallegedexenrptiort. AnyviolationofSectionT03l.5byany applicarrt flor u perrnit subjects the applicanl to a civil penalty ol'not rnore lhun I'ive hundred dollirrs ($5tXt1. _l.as owncrol'thcpropcrly,orrnycrnployc'cswithwagcsasthcirsolccornpcnsalion,willdothcworkalxlthcstnrcturcisnot interded or oflered frrr sule (Sec'.7(]14, Business and Pnrfessions Code: The Conlraclor's Liccnse l-aw tloes nol apply to an owner of thc pr)[]cny rvlxr builds rlr inrproves thcreou. arxl wlxr drrcs such wort hinrself or lrcrsell'or llrouglt his or her owtt employees. providcd that such improvcrnents are not intcndcd or ol'l'crcd l'or salc. Il. howcvcr. thc building or improvcmcnt is sold wilhin onc ycar of conplctiotr, the Owner Buikbr will luvc thc burden o[pnrvirrg tlurt lr or she tlid rxrt buikl or impmve thc pnrperty ftrr tlrc purynse of sale). _1. as owner of the pr)pefly, anr exclusively contracting with licensed conlrrrclors to conslruct tlrc project (Sec. 7(X4, Busincss ard hulbssirxtCode: TheContractor'sLicerrseLawdrrcslrota;rplytoan()wnerofpropertywhobuikJsorimprovcsthereott. and who conrracts for such projccts with a Conlractor(s) liccnscd pursuilnt to thc Contraclor's Liccnsc Law). _l anr exenlpt urrtler Section_. B. & P ,,",", 11 18 \ l-0 L,0 I hcrc'by allirm unclcr pcnalty of pcrjury onc of thc lirllowing _l havean<lwill nnintainaCertilicateofConsenttoSell'-lruureforworkers'conrperxation,as providetl firrbySection3T00ofthe Latxrr Corlc, for thc pcrformancc ol'thc work lirr which thc pcrmit is lssued. _lhave:"urdwillnraintainworkers'compensationinsurauce,as recpriredbySection3T00oflheLaborCotle,titrtheperfirrmaltceof tlrc w<lrk firr whiclr this prnrit is issucrt. My workcrs' conrl)cnsiltiort iltsurancc carricr arxl grlicy nunthc'r arc: Policy Nurrrher: Expires: _l ccrrity thut in thc pcrtilrnruncc of thc work tirr which tlris pcrnrit is issuctl, I slrall not cnpk)y any pcrson in any manncr so astohccorrcsuhjccttothcworkcrs'cornpcnsationlawsol'Calilbrnia.arxlagrccthatif lshouldhccott*subjecttottrc workers' conrpensation provisiorrs of Section 3700 of the Latxrr Code, I shall, forthwitlr conrply with tlrose provisiorts. WARNING: Failurc to securc workcrs' comJrcnsrtion covcmgc is unlawful. antl shall subjcct an cntphrycr to criminal pnaltics antl civil lines up to onc hundred thousartd dollars (Sl(X).(XX)t. in to the cost of'cornpensation. damages as provided for thc atlorney's fees. I hcrcby allinn undcr 1^-nalty of pcrjury that I arn liccnscd undcr Chaptcrr 9 (cornrnencing with Scction 7ffn) o[ I)ivision 3 ol' thc llusincss and Profcssions Ctxlc. inrl nry liccnsc is in t'ull lirrcc and ct'll'ct. Liccnsc Nurntrcr: CONS1RI,'(ITION ],I.:NI)I NG A G I.]NCY I hereby aflrnr under Juraltyof per.jury tlut tlrre is a constnrctiorr leudirg agerry tbr the Jrrftrrnurre of tlr work lbr which this permit is issuctl (Scc. .1097, Cit'. C.). Le'rtdcr's Nalnc: Lcnrlcr's Arltlrcss: APPI,ICA NT DECI,ARATION I hcreby affrnr under penalty of perjury one of the followirtg declaratiorts: Dcnxrlition Pernrits-Asbstos Notification Federal Regulations (Title .10, Part6) _Required [-etter of Notification _I certity that the federal regulatiorrs regarding asbestos renpval are not upplicable to tltis project. _l certify that I have rcntl this application and state that the above inlornution is correct. I agree to conlply with all City antl County atxlvc mcntioncrl propcrly lor Applicant or Agcnt l't rrrritrr nirlDt: Rev. 08-07-2015 1'P'ua*rr""V t purp()scs. ,*,,11 L{l'?,o?d,