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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/S!G COMMENTS owNuR lrt,il,l)ul{ t)ut.cARA'I'I()N <br />I hereby tffirnl undcr peDilty of perjury that I nn) exempt frcm tlrc ContracloN' l-icense l-aw for the following reason (Sec.70Jl.5 <br />llusincss 0nd Ptolcssi()n Codc): Any City or County which rcquircs a Jrcrrnit !) conslnrcl, altcr. irnprove, dcrnolish or rcpair any <br />slructlrc. prior k) irs issuance. also requircs the applicanl lirr such p€rmit lo frle a signed slillcmenl lhfit he or she is licensed pursuont <br />to thc nrovisionr ol'th+ Conlractor's l,iccnsed l-nw (Chaptcr 9. Comrnencing with Scction 7(xx) ol l)ivision 3 ol lhc Busincss and <br />ProtessionsCode)orthutheorsheisexenrptthcrclionrandtlEhasistbttlEallcgedcxenrnti(il1. AnyviolationofSeclion?03l.5byrny <br />rpplicrnl for r pcnnil subjecls the npplicanl lo a civil perrihy oI not rmre thrn five hundrcd dollnrs ($5(x)). <br />_1. as owncr ol'thc pro[Eny, or my employccs wilh waScs as thcir $le compensation, will do lhc work and llE slrclure is mt <br />intefthd or offcrcd for ule (Se.7(X.1, Busincss ond Pmfersions Code: Thc Conlractor's l-iccnrc ljw does nol spply lo an owncr of <br />the pmlEny wk) builds or itr{,mves tlMm[ ilrl wlp d(Ds s$h work himself or hcrself or throu8h his or her own employes. <br />pror idcd rhat slch impn)vcrrcnts &e mt interxlcd or olTcrcd for sb. Il. howevcr. lhc buildiog or in{trevcmil is sB wilhin onc }tfi <br />ofconqrlctirn, the Owrcr Buil]er will have thc burdcn ofpruvin8 llu{ he or she did not build or impmvc 0rc prepeny for th. puryn* of <br />sb). <br />_1. ils owner ofthe prope(y, am exclusivcly contrscling with licensil conlraclors lo con\lruc1 llE pmject (Sec. 7044. Business <br />and l\rrlbssiruCoclc:TheCoiltractor'sLiceD\e[,awdoclnotapplytoanownerofpropertywhohuildsorimproveslhereoD. <br />nnd who conthds lbr such projccls with a Contraclor(s) liccnscd pursuail (, llf,i Conlraclor's Liccnsc Law). <br />-l <br />am crcmnl undcr Section-. B. & P C. for lhis rea\on. <br />A--... <br />W()RKllRS' COI\lPl:NSA'l'l()N <br />DECLARATTON <br />I hcrcby rlllrmundcr pcnahyof pcrjuryonc of lhc lbll(,wing dcclaratioilsi <br />_l have and will nuintain a Cenilicate ofconscnt b Self-lnsurc for workers'compensati()n, as povided for bySection 3700 oflhc <br />Latxrr Cnlc, for thc pcrformrce of the work lor which th! permit i\ Lssued. <br />and will ntairilrin workers' conrpensali{)n inrurancc, as required hy Sectiul 3700 of the Lxhor Code, for the perforDrance of <br />lor whlch this pcrnril is issucd. My w(,rkcrs' conrpcnsati()n insurancc catricr ilnd Ix)licy ntrDhcr uc: <br />7 6 - zr'zl <br />_l ccf,ifi thar in rhe lErformance of rhe work for which this pcrmil is issued, I shall not cmpby any person in aoy lMnct <br />$ as to becom suhjcct to lhe workcrs' comlrnsalion laws of Califomia, and agrcc thnt if I stbuld tEcorc subjrcl to the <br />wodiers' conlrEn5ation provisions of Section 1700 of thc tibor Code, I sttsll, fonhwilh comply wilh lhoe prcvisioB. <br />\YARNINC: Frilurc lo sccurc workcrs'conrlEnsali(,n covcnlgc is nn(l shnll suhjrcl an cnrphrlcr to minal pnaltrs aml <br />civil lines up to onc huildred lhousand dollars (Sl(x),Uxl). <br />Seclion 1076 ofrhE titx)r Code, interest and alk)mcy's fecs. <br />the cosl of compcnsition, damges as providcd for the <br />{u,,",?nu- 7 <br />I,I(-]]NSI,)) C( }NTRA('ToR <br />I)I.]('I,ARATI()N <br />rm licflrsed undcr l)n)visi(rn ol Chipt.rI hcrcby aliiiln und!'r pcnally ofpcrjury thal I 9 (cornrrcncing wilh Section 7000) of I)ivision 3 <br />of lhc Busiocss and Prcfcssiom Corle, ml my license is in full fore and cffect.2{zf"r <br />CONS'I'RI)CTION I,T]NI)INC AGI.:NCY <br />issucd (Scc. :]o97, Civ. C.). <br />Lcildl'r's Nrnrc. <br />- <br />lrntltr's Addrcss: <br />AII!!$NLDEEIAEA'IION <br />I hcrcby uffmr under pcnahy of perjury onc of thc followinB dslarat ions: <br />Denelition Permits-Asb€stos Notification Fedcral RcSulations (Title 40, Pan6) <br />-Requtcd <br />lJtt.r of Notification <br />regarding ashcst)s rcnx)val {re nol ilpplicrblc lo lhis proiecl. <br />thnl the nbove informnlion is correcl. I xgrcc lo comply wilh nll City rnd County <br />und herebyauthorize represerxalivcs ofthis City and County to enler uF)n tlE <br />,ror", ?-Co- 4 <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVl nsu lation <br />Roof Sheathinq 4ll,tl"d D ke9? <br />Shear Wall <br />Framing <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />J\4asonry <br />Pool Fence <br />T-Bar <br />Handicap Req \ <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />t. <br />FINAL <br />Certificate of <br />Notes, Remarks, Etc. <br />/ <br />a <br />I <br />Rev.0B-07-2015 <br />U0/zrt trt -.lX-,tt )fl