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BUILDING. INSPECTOR RECORD <br />Rev.08-07-2015 <br />SITE.WORK DATE ID/SIG.COMMENTS owNI.tR lrtIl,t)t:R Dt]t,c,tRATIoN <br />I hcreby rffirm under penalty of pcrjury that I m cxenrpt fronr lhe Contractos' LiceDsc law for the following rcason (Scc.7031.5 <br />lJusincss rnd Prol'cssi()n Codc)r Any Cily or County which rcquires a Jtrrnit to conslrucl, altcr, irnprovc, demolish or rcpair any <br />slnrclure.priortoils issuance.alsorcqilircslheapplicliltfi)rsuchpernritl(]tileasignedstatemenl lhatlEorshcislicensed pursuant <br />ro thc f,mvisions ol rhc Cohlraclor's l.iccnrcd [nw (Chapter 9. Commcncin8 wilh Section 7(XX) of l)ivision 3 ol lhe Business and <br />P(rtssionsCode)orrharheorsheiscrempltherehonrarrlthcbasisti)rlltallegedexemprion. AnyviolariulofSeclionT0Sl.5byany <br />rpplicrnt Ibr r pennit subjects the npplicant to r civil pcnihy of not rmre lhiln five hundred dollars ($5{X)). <br />_1, as owncr ol'thc propcfly, or rny crnpbyccs wilh wagcs as thcir solc cornpr:nsation, will do thc work and lhc stnlcturc is not <br />iilcilded orofferedforule(5*.7044.BusircssandPmfessionsCode:TheConlriclor'sLiaenscliwdoesnotapplytoanownerof <br />thcpn)Fny wlx)huildsorimprovesthcrdn,arlwlbd(Essuchworkhin)selforhcrselfortfuouthhisorhcrowtremployees. <br />pro\ idcd lhat such improvcrEnts &c Rn intcrdcd or ollcrcd lbr slc. Il. howcvcr. rhc tf,riHiog or irprovemnl is soU within orc ycar <br />ofconq:lctirrl the Owrrr Builder will lutvc thc burden ofproving lhd lE or shc did il{ buill or inrpruve the profrcny for tlE pu(ns of <br />salc). <br />_1, as owner of the propcfly, am exclusively conlractinS wilh licensd conlraclors to construcl lhc prc.iect (Scc. ?(X4. Business <br />arxl PnrllssirrC<xlerTheConlractor'sLicenseLawd(Es0ollJrplybanownerofpropcnywhobuildsorinrprovesthereon. <br />and who contractsforsuchprojcclswithaConlmcb(s)licen*dpur\uadtotheCootractor'sLicenscbw). <br />-IlnrexemPtnnderseclion-,R,&P,C-tilrthisreasou,l)alr:_ <br />woRKt:tts' coMP!:NsA'fl oN <br />DECLARATI0N <br />I hcrchy amrm undcr pcnalry ofperjury onc ofrhc followin8 dccleations: <br />_lhaveardwill MintainaCeflit'icatcofConsentloSclFlnsurcforworlcrs'compensation,as prcvidedforbyScctionJT00ofthe <br />\Ftrrr Gxlc, tor thc pcrlorlr1mc of rhc work lor which ttr. lErmil i\ is\ucd.t- <br />{hor.ondwillnHintrinworkeB compc[salioninsurance,as requircdbyScclion3T0OofthetlborCode,forthelErfomrccof <br />thc wi,rk lilr which this pcrnrit is iosurilncc ca[icr ifrl lxrlicy nunrtrr nrc: <br />- .Zuric*t lN Sl/trcrttf e <br />Policy Nu <br />a tl'rt )r) <br />_l ccnity that in thc Nrlirrnuncc ol'tlrc work for which this pcrmit is issucd, I shall not cmploy nny Jrcrson in any manncr <br />so ss lo hccorrc subjcct h lhc workcrs' conrpcnsatior laws ol'Cali fornia, aDd sgrce thal it I stnuld becorre subjcct to lhc <br />worlers conrlrcnsatioD pruvisions ofSectiotr 1700 ofthc l-attr C'ode, I shall, fonhwith rnnrply with thow pruvisions. <br />WARNING: Failure k) scure workcrs'compcnsalt)n covcrugc is unlawful. and shall subjcct an eDployer to oiminal pmltics and <br />civil lines up to one hundrcd thousand dollnrs ($l(X).(xx)), in addilior lo lhe cost ofcoillpensation, darrurgcs ns provided for thc <br />Sectior 1076 oflhc lrtDa C(xle, interesl and atkrrrey s feer.( <br />f <br />I hcreby allirm undcr pcnahy oIperjury rhal I am licen$d Chaptcr 9 (cornrrcncing wilh Scclion 7mO) ol l)ivision l <br />of tlr llusiness and l'roli'ssirrns Cotlc. md nry liccn\c is in fill li)rcc ril(l ('icct. <br />Liccnsc Nurnla'r:6bA 774 <br />-|2D <br />CONSTRTJC'TION I,I:NT)INC AGI.:NCY <br />I hcrcby allirn under Jenalty of periury thal there is a con\lnlcti(nr leildilS agerEy tor rhe fErfrrrmance of the work fbr which th$ fEmit is <br />issucd (Scc. :1097, Civ. C.). <br />ktrdcr's Name: <br />[-cn(lcr's A(klrcss: <br />APPLICANT DECLARATION <br />I lHeby rffmr under pcnalty of perjury onc of the followirrg declarations: <br />DenDlirion Pernrits-Asbestos Notification Federal ReSulatiotrs (Title 40, Pnrt6) <br />-Retluired <br />trtter of Notification <br />\ Ilcaily rha( rhe federal relulrrioDs reStrding rsbesbs renxrval ure not applicable b rhi\ pr().icd. <br />ffi*n* ,'nnt traue rcr.l rtris a-pplication and slale lhat lhe nbovc irfornidtion is corecl. I ngre to conrply wirh all City anrl County <br />;;;-:,-:,ffii""i-"'W- ^," - 2-tv'ao <br />Pcmritee name (prinl r, <br />U <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 />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />lt/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enoineer Final Report <br />Flood Zone Certif <br />I t^ <br />FINAL <br />Certificate of Occu <br />Notes Remarks Etc. <br />- <br />6/u/0'7n ./D