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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BTJILDER DEL(}RATION <br />I hcreby afftrm undcr pcndty of perjury that I m excmpt frcm thc ContractoB' Liens kw for thc following qsn (54.7031.5 <br />Busincss ard Pmfcssion Code): Any City or County which rcquircs a Jmit to @nstruct, alts, imprcvc. dcmlish or rclEir ay <br />strctu.q pritr to its issure, nlso rcquircs thc +plicant for such lrcmit to fib a sign€{ stalcrcnt that hc or shc is liensd pursuot <br />to thc Fovisions of $c Contractor's Liccnsd law (ChBptcr 9. Comrcing with Selion 7000 of Division 3 of the Busircss ud <br />PmfcssbnsCodc)orthathcorsheisexcmpttlrefmmrndthebesisforthcsllcgcdcxcmption. AnyviolationofseiionT03l.5byany <br />opplicant for ! pcrmit subjixts thc opplicant to a civil pcnalty of not morc lhs fivc hundrcd dollus ($50O). <br />_1, as owncr of thc proF,crly, or my employccs with wagcs as thcir sole compensation. will do thc work Bnd thc structure is rnt <br />intcnded or oft'crcd for sale (Scc.7044, Business and Profcssions Code: Thc Contractor's Liccnse [:w does not apply to an owner of <br />the propcrty who builds or inrproves lhcrcrrn, and who does such work himself or herself or thmugh his or hcr own cmployces, <br />providcrl lhat such improvcrncnts arc not interdcd oroffcrcd for salc. lf, howercr. the buiUing or inqrrovcnrcnt is soH within one )rcar <br />of comphtion lhc Owncr Buildcr will have thc burden of proving that hc or shc did not build or improve thc propcrly for thc puryxrsc of <br />salc). <br />-1. <br />as owner of thc property, am exclusivcly contracting with licenscd contractors to construct thc pro.icct (Scc. 7M4. Business <br />and Protbssion Codc: The Contraclor's Liccnsc Law docs not apply to an owncr of progrcrty who builds or improves thercon. <br />and who contracts for such projccts with a Contractor(s) liccnscd pursuant to the Contractor's Liccnse taw). <br />--l <br />arn cxcmpt undcr Section-. B. & P.C. for thls rcas<ln. <br />llirlt': ()rrttcr. <br />IVORKIiILS' COI\I I'ENSATION <br />DECLAIIA'I'ION <br />I hcrcby aflirnr undcr pcnalty of prjury one of thc following dcclarations: <br />-_l have and will maintain a Ccrtificatc of Consent to Self-lnsurc for workcrs' comlrcnsation, as providcd for by Section 3700 of thc <br />l;rbor C-odc. for thc perfornuncc of thc work for which thc pcrrnit is issucd. <br />_l have and <br />thc work lbr <br />will rnaintain workcrs'tnsuralre. &s by Section 3700 of the labor Code, for the performance of <br />is issucd.conrpcnsation carrier atxl nunrbcr ire: <br />rD <br />Policy ,a /-/-L/ <br />_l ccrtify that in thc pcrformarrce of the work for which this pcrmit is issucd. I shall not employ any pcrson in any rnnner <br />so as to bccomc subjcct to thc workcrs' compcnsation laws of California. and agrcc that if I should bcconrc subject to thc <br />workcrs' compcnsation provisions of Scction 3700 of thc l-:bor Codc. I shall. forthwith comply with thosc provisions. <br />WARNING: Failurc to sccurc workcrs' compensation covcragc is unlawful. and shall subict an to ancl <br />civil fines up to onc hundrcd thousand dollars ($100.0001. in addition to the cost of compensalion,thc <br />Scction 3076 of thc l-abor Codc. intcrcst and <br />D I <br />I hcrcby aflirrn undcr pcnalty of prjury thal I arn liccnsed of Chaptcr 9 (comnrncing with Scrtion 7000) of Division 3 <br />of thc Busincss and Professions Codc, and my licensc is in full force and effert. <br />0Liccnse <br />t <br />I hcrcby sffirm unlcr Fnaltyof tE]jury that thw is a construction lending agercy for thc pcrforme of thc rcrk for which this Fmit is <br />isrued (Sa. 3097, Civ. C.). <br />lxndcr's Nam: <br />lrndcr's Addrcss: <br />APPLICANT DFCI ARATION <br />I hcrcby afl-rm undcr lrcnalty of ;rcrjury one of thc following dcclarations: <br />Dcmolition Pcrmits-Asbestos Notification Fedcral Regulations (Title 40. Part6) <br />-Requircd <br />l,ctter of Notification <br />lbdcral rcgulations rcgarding asbcslos rcnnvularc nol uplllicable to this project. <br />statc that thc atnve irrfornurtion is <br />atxlve <br />Applicant or <br />propcrly for <br />Pernritee nunle <br />this <br />purposcs. <br />and hcrcby <br />I agrcrc <br />./,3k)thc <br />Set Backs <br />Forms/Steel/Holdowns ?YT <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bf loo r/VenUI ns u latio n <br />Roof Sheathing <br />Shear Wall <br />Frami ao <br />Insulation/Enerqv <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 />Engineer Final Report <br />Flood Zone Certif . <br />FINAL tLl t1 lu D**x,/ <br />Certificate of Occupancv <br />Notes, Remarks, Etc. <br />2)+:)a <br />v <br />Rev. 08-07-201 5 <br />rln*Vo Dfh^b <br />I all City and County <br />and