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BUILDING. INSPECTOR RECORD <br />Rev.08-07-2015 <br />SITE-WORK DATE ID/SIG.COMMENTS oWNER BUlt,l)ER l)lll-CARA'IION <br />Iherebyaffirn)unde(penaltyofperjurythalIamcxemptfronrtheContractos Licensclrwforthefollowingrca$n(Scc.7031.5 <br />llusincss and Prolcssion Code)r Any City or Counly which rcquircs a lErmit lo con\truct. altcr. irnprovc, dcmlish or rcpair any <br />stnrcturc. prior () its issuance. alro requires lhe applicanl tbr such p€rmit lo tile u signed slalement lhat he or she i{ licensed pursuant <br />to lhc pmvisions ol-lhe Contracor's l,iccnsed liw (Chapler 9. Cohhcncing with Section 7(XX) ol'Division I oI lhe Busincss and <br />ProlessionsCode)orthatheo,\lEiserempttheretromandllEhrsisfbrtlEallegedexemption. AnyviolarionofSecrionT03l.Sbyany <br />npplicant for a pcnnit subjecls thc applicant to r civil pennlty of nol mre thnn llve hundred dollars ($5U)). <br />_1, N owncr ol lhc pro[rcrly, or my crnployecs wilh wagcs as thcir solc cornpcnsalion, willdo lhc work and lhc \truclurc is not <br />ir{eriled oroftercdforsale(Sa.?(N,{.BusircssandPmfessiorsCoderTheConlrxck)r'sLicenseliwdoesnotapplyloanownerof <br />thepmpcny wlx)buildsorimprovcslher@[urlwhod(EssuchworkhimselforlErselforlhroushhisorlrerowilemployees. <br />pr()\idcdlhalsuch irnpmvcrrcntrtrcretinlerdcdorr)ll'crcdlorsrlc. Il.hoscvcr.lh.buildingorirn0rovcmntissUwilhinoncycar <br />ofconpleli(n\ lhc Owner Builder will have the buRlen of pmvinS that lE or she did not huild r)r impmve the pr)Fny for tlre pu4xrse o[ <br />snlc). <br />_1, a$ owner of lhc propcny, am axclusivcly contraclinS with Iiccn*d conlrack)rs Io conslrucl thc prcject (Sec. 7014, Business <br />arxl holissir Crxle: The Conlrachr's License Law does nol apply to an owner of propeny who builds or inrproves lhereon. <br />and who contracts for such p(rjccts wilh r Contracto(s) licen*d pursuanl xi thc Contraclor's Liccnse kw). <br />-lilmexemptuilderSection-,B,&P,c,1ilthisrcas(,D, <br />WORKtr]lLS' CoMPENSA'IION <br />I hcrcby allirm under pcnaly ofperjury one ot,t" tnft*ingffi <br />/ <br />-l <br />have arxl will nBinlain a Ccn illcatc of Corscnt to Selllnsurc for workers' compeDsation, as pmvidcd for by Scction 3?00 of rh. <br />- -lrhor Codc, for thc Jrrlormmc of thc uork l'i)r whrch rtE frcrmir N i\\uedOL <br />t'-llrrveanrlwillmaintainworkes (ompensslioninsurance,as r€quiredbySection3?00oftheLaborCode,forthcperfornurccof <br />. rtr work tbr which lhis permir is issued. My workcN' compcnsation insurun;c clricr und F)licy numbcr tre:'/.*-, OLD psNgr-lo <br />i r.,.r *,,,*.. <br />-l <br />ccriti that in thc perfbrnrancc of the work t)r which this prnril is issucd, I shall not enrpkry any pcrson in uny manner <br />$ as to bccorE suhjccl to the workcrs' conrpcnsation laws of Calilbnria. and agrcc lhal if I slnuld [rccorm suhjcct lo thc <br />worlcrs conrpcnsatioD provi\ions ofSaction 37G0ofrhe Labor (ixle, I shall, fonhwith ronlply with rlrcs prcvisions. <br />WARNING: Irailurc rr sccurc workers'compcnsution covcngc is unlswful. md shnll subjcq im cmploycr k, oiminrl Fnaltics md <br />civil llnes up to one hundred lhousand dollxrs ($l(X).UXD. in trddilion lo lhe cost ofconrpensation, damngcs as provided for the <br />SectirD -1076 Codc, irileresl an(l rtt)rney s tles.J (+e.r..t <br />LI( ENSl,ll) ( ()N'tR,\(1()R <br />I)ti( t./\R,\'t'()N <br />I hcreby all'iiln undcr pcnahy ol pcr.jury that I am liccnscd undcr provision ol'Chaplcr I (cornmcncing wilh Section 7000) ol Division 3 <br />ol thc Busincsr and Profcssirrns Code. and nrv liccnsc is in tull li)rcc ud cllicl. <br />//Liccnsc Nurnhcr:49o'tr t- <br />z! <br />CONSTRT'CTION I,I.]NDINC AGI.]NCY <br />I herehy atlirm under lxnalty of pcriury that lherc is a constnrctirrr lerdilg ageney Lr the pcrfrrrnrance of the work fi)r which lhis pcrnrit is <br />issucrl (Scc. lt)9?. Civ. C.). <br />LcD,l.'r's Nunrc. <br />kn,lcr's Addrcsr: <br />APPLICANT DNCLARATION <br />I lrreby aflm undcr penalty of perjury one of the followirB dslaralions; <br />Dcnrulition Permit$-Asbestos Ndification Fedcral ReSulalions (Title {0, Pa(6) <br />_Required trttcr of Notification <br />_l cenity rhar rhe lederal rshcslos renx)vrl are not at)t)licrhle ro this pr)icct. <br />-l <br />.enify thdl I lxrvc read this that lhe rbovc infomution is corect. I agre to comply wilh all City <br />oftlinances and State Laws reL[irlg nnd hercby authorize rcpresernativcs ofthis Crty aM Co[ilty lo uprn tlrc <br />atxrtc nrcntioncrl propcty tbr <br />Applicont or Agcnt <br />\ I'rmrilee nahc (prinl):@orY <br />ion <br />?lotw <br />ty ,7D <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenVl nsu lation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Enerqy <br />Drvwall <br />Ext./lnt. Lath <br />Brown Coat <br />lt/asonry <br />Pool Fence 1 <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />.t I I --\ <br />FINAL 7//7/n N'M 2r/ <br />Certificate of Occu <br />Notes, Remarks, Etc.