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BUILDING. INSPECTOR RECORD
<br />Rev.08-07-2015
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNIIR lltJll,l)llR l)l'l,l,CA RA'l'ION
<br />I hereby affirnr under penulty of perjory that I anr etempt from the ContracloB' Licensc llw for the following rca\on lsd'.7011.5
<br />lru\incss and Proltssion Codc): Any City or Countv which rcquircs a lDnnit lo construct. alter. lnprovc. dermlish or rcpair any
<br />stnrctrrre, pri()r lo its issuancc. also requircs the rpplicrDr for such ltmil k) tile a signed slatemcnt lhat IE or shc is liccnscd purstrant
<br />b thc nrovisions of thc Conlractor's l,iccnscd Inw (Chaptcr 9, Cornrnencing with Scction 7(XX) ol l)ivision 3 ol thc Busincss and
<br />ProtcssioDsCode)orthalheorsheisexempltherelionrandthehasislortlEallesedexempti(nl- AnyviolaliulofSectir)n703l.5hyaily
<br />rpplicrnt for r pcrrnit subjects the npplicant lo n civil perultyofnot rmre thrn llve hundred dollars ($5(x)).
<br />_1. as owncr ol thc pro[E(y, or my cmployecs with wagcs as thct solc cornpcnsation, will do the work and thc sttuturc is not
<br />iileiled or offcred for sle (Se.7(X4, Business and Profcssions (ixle: The Conlraclor's l-iccnsc Law does nol apply to rn owncr of
<br />the propeny wlx, build\ or iilprows lhcrsm. nxl wh) d(Es such wo* hinrselirr lErsclfor tlrou8h his or lEr owil enrployees,
<br />pr)ridcd that such improvcrmnts &e mt inlcrded or ollercd for salc. Il. howcvcr. tlE building or rnprovcmnt is sld wilhin one )re
<br />ofcompleti(D, tlE Owrer Builder will have lhc burden of proving thnt hc or she dirl not build or imprcve lhc prop€iy for thc purlFse of
<br />sale).
<br />_1, as owner ofthe propefly, an cxclusivcly contractintl with licensed conlrMlors 10 conslruct the p$jed (Sec. 7(X4, Business
<br />and PnrlessirrrCode:TheContractor'sLicenseLawdoesnotapplytoanowneroIpropertywhobuildsorinrprovesthereol.
<br />and who con[acts for such projccts wilh a Coolracktr(s) liccnsc(l pursuant kr thc Contrnclor's Liccnsc Law).
<br />-lanretenlln!ldersecli(!l-'B,&P,Clbrthisreavlr'Date:-
<br />WORKIIRS' C()[rPl)NSA't l()N
<br />DECLARATIoN
<br />Ihcrcbyaflirmundcrpcnaltyofperjur-v<,ncofthclbll()wingdcclararrrns:
<br />_l have and w il I nuintd,r a Cert iticate o f Consent b Se lt:IDsure frrr workers' co nrpensat io n, a s provided for by Secl ioil 3700 of t he
<br />Latxrr Codc. f()r lhc performrcc of thc work lbr which lhc pcrmil i\ issucd.
<br />tlrc w(,rk lin'which this is irsucrl. My w(,rkcrs'insurancc crricr aftt Jx)licy numhcr ilc:
<br />\e_
<br />l']olicy
<br />_l ccnili that rn thc Frl()rnuncc of thc work fbr which this prnrit is issucrl. I shall not cmpk)y any pcrson in any n'tf,ncr
<br />soastohccorrsuhjccttothcworkcrs'conrpcnsationlawsofCrli[ornia,andnsrcclhaliflstnuldbccolBsuhjecltoltc
<br />worlers'conllrnsrtionprovi\ionsofsectionlT00oftheLatrcrCodc.lshall,lirnhwithcomplywilhtho$prcvisions.-
<br />WARNINC: ,;xilurc to sccurc workcrs'conrlrcnsalion covcnrgc is unlawftll, and shall subjcct an cn4rloycr kr fininrl pcnaltics an(l
<br />civil llnes uf h one huDdred thousand dollars ($l(X),(XX)), in addition n the cost of compensrlion.damxges rs provided for lhc
<br />Sccli{,n 1076 of the trtx,r (l(f,le, interest atrd
<br />(-
<br />I hcrcby allirm undcr r_nally of perjury lhat I am liccnscd undcr 9 (cornrrcncing wilh Scclhn 7(XX)) ol Division :l
<br />of thc Busincsr and Prol'cx\i()ns Codc. nn(l nry liccnsc is in full ti,rcc ql.c'lti'ct.
<br />l,iccnsc
<br />'ca\C1
<br />I hcRby aflirnr under FEnalty of pcriory that thcre
<br />issucd (Scc. 3097, Civ. C.).
<br />lxndcr's Nilnlc:
<br />agerrcy li)r Ihe Frli)rnuilce ofthe work lor which this frcrnril is
<br />APPI-ICANT DECI,ARATION
<br />I lreby affmr under penalty of perjury one of the folk)wirtg declarations:
<br />Denulition Pcrnits-Asbeslos Notification fedcral Regulations (Tille 40, Pan6)
<br />_Rer!ircd lrltcr of Notificalion
<br />Z Lcedity rhat tlE fcderal rcaularioN rcgdding asbcstos rcft)val aE not applicahle to rhis prcjecl._\
<br />_l cenify thal I havc read this npplicirlion and stale thal lhc above inlbrnralion i\ corect. I r8r@ b comply wilh all Cily and County
<br />ordiDances ard Stute Laws reLilirlg to buildtrlg corlslructiur. iuxl herehy autk,rize rpresenhtives of this City and County b enler ulxi the
<br />atxrrc nrcntionctt propcny tbr .\
<br />Applicnnt or Ag([t
<br />P(nnilce hanre
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl ns u lation I l ,r'-
<br />Roof Sheathino QlzYl-Lrt )rH-;f
<br />Shear Wall I I
<br />Framinq
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />[\4asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif.
<br />FINAL 4/rs lgu zt': //.r.rt{-l! 1
<br />Certilicate of Occupancy ,U
<br />Notes, Remarks, Etc.
<br />\I
<br />k'ndcr's Ad,lrcsr:
<br />,",",r.{,?< l2c)
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