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BU!LDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNI]R BT'TI,I)EIT I)t,]I,CARATION
<br />Iherebyrffirnrunderpenaltyofp€rjurythatIanrcxen)ptfronrtheCbntractoc LicenseLawforthcfollowingreason(Scc.7031.5
<br />llusincss and Prcltssion Codc): Any City or Counly which requircs a prmit h construcl, aller, irnprovc, dcrnolish or rcpair any
<br />stnrcture,priork,ils issuance.alsorequirestheapplicnnltbrsuchpemlit(,fileasigiledslatement thatheorsheisliccnsed pursuant
<br />to lhc provisionx ol thc Conlractor's l,icensed Law (Chaptcr 9, Cornrncncing wilh Seclion 7000 ol Division J ol lhe llusincss and
<br />P!,lcssionsC(de)orthothcorsheiscxcmplthcrefioDaDdthcbasisfirrtlEallegedcxemption. AnyviolatioilofSectfurnT03l.5hyany
<br />ilpplicnrl lbr n permit subjects lhe npplicanl lo n civil perulty oI not nmre lhnn five hundred dolhrs ($500).
<br />_1. a\ owncr ol lhc proFEny, or my employccs with wages as lhcir solc compcnsalion, will do the work and lhc stMuc is mt
<br />inleilcd orofferedforsle(Se.7(X4.BusincsssndProfassionsCqle:'I'hcContrrctor'sLicenscbwdocsnotapplyloanowncrof
<br />the popeny wlp builds or imFoves lhersll ed wlD d(Es srch work himself or lErself or through his or her owtr employecs,
<br />pr)lidcd thal such inpNvcrEnts de ml interdcd orollered lor slc. Il. howevcr. the buiUing or inprovemnt is sld within om yld
<br />of conrplcli)n, lhc Owrrr Buikjer will lu€ the burden of pmvirg llu lE or she did Nr boilil or inprcve $e pmJrny for thc puqn* of
<br />sh).
<br />_1, as owner of lhe pmpcny, am exclusively contrdcting with licen$d aonlracloA to conslruct lhe pmjed (Scc. 7(X.1, Burincss
<br />arxl l\rtlsslrnCude:TheContacrcr'tLiceilseLawdrrcrnotapplytoanownerofprope(ywhobuildsorintprovesthcreon.
<br />and who contractsforsuchprojectswithaContmcto(s)licc$cdpursuuttolhcContractor'sLicense[lw).
<br />-IamexemplUnde'Section-.B,&P,c,li)rthisrcason,lr.r-._ 6-^-.
<br />WORKI:RS' CoN,IPl]NSA'I'ION
<br />DI]CLARATION
<br />I hcrcby alfirm unde, pcnakyof perjuryone of the ti)IIowing dcchrrlions:
<br />-l
<br />haveiudwill nuinlainaCeftificateofConsenthSelf:lnsurei(rrworlers'compensation,as pmvidedtorhySectionS?00oftha
<br />Latx'r Corlc, lbr lhc pcrlormncc ol thc work lor which thc pcrmit i\ i\sucd.f)
<br />-1dlBhavcandwillmnintainworkers compensalioninsurancc,as requircdhySeclionsT00ofthet2borCodc,forthcpcrfornutreof
<br />'\,{hc w,rrk trrr which this pcrmt is issued. My workers' comlrcnsation insurlncc cmicr aftl frclicy numhcr ilc:
<br />l'olicr
<br />_l ccrify lhat in lhc Frlbrmnce of rhe work for which this pcrnlir is issucd, I shrll not cnrploy any prson in any nunncr
<br />$ as to bccl)rro subjcct lo thc workcrs' compe nsatioD laws o[ Cllilon)ia. and a8rce lhit if I slnuld becotrc subjcct to thc
<br />workers' compensation provisions of Section 1700 of the trkrr Code, I shlll, fonhwiih comply with thos prcvisions.
<br />WARNINC: Failurc k) securc workcrs'comfEnsation covcragc is unlawful. an(l shall suhject an employer o crimnrl frcnallics ud
<br />civil liDcs up to one hundred thousand dollnrs ($I(X),(XX)), in ilddilion lo lhc cost ofconrpensation. dnma8cs as provided for lhe
<br />Secti 'n J0?6 of the Latr,r Code, inreresl an.l artomey r lec\. A a)
<br />,r,,", 7/9/30/0 *K #%----I;ICENSFD ('oN"TRA (:TOR
<br />DECLARATI()N
<br />I hcrcby al lirm undcr pcnahy of perjury that I am licenscd undcr provist)n ol Chapter 9 (commncing wilh Secrion 70(x)) ol-l)ivision 3
<br />of lhc Busincs\ and Profcssions Codc. md mv liccnsc is in full li)rc afil ellcct-
<br />l-iccnsc o
<br />o
<br />CONSTRI.JCTION I,ENT)ING AGNNCY
<br />I heEhy afrtrm under fEnalty of p€rjury tha( thrc is a constructim lerdioS aSeRy t'or the perfomarce of the work lbr which lhis lEmit is
<br />issucd (Scc. 1097, Civ. C.).
<br />14ndcr's Narnc:
<br />Irnrlcr's Adclrcss:
<br />APPI,ICANT DECLARATIoN
<br />I hercby uffmr under penalty of perjury onc of the followin8 declararioDsl
<br />Den)olition Permits-Ashestos Notification Fedcral ReSulations (Tirle 40, Prn6)
<br />_Required trtlcr of Ndificalion
<br />_l ccaily lhat tlE ftderal rcgulations rcgur!ing asbesk)s renx)vrl are not applicable to this proj*t.
<br />i\ corecl. I agree to comply
<br />repre\erlatives of this CIy
<br />with all City and Countl
<br />and County k) eilter uBu the
<br />Applicunt or AScnt
<br />I'(rmilft name
<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
<br />Shear Wall
<br />Framinq
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />[Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputv Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />I rl ^a4
<br />FINAL 0,
<br />tt (//ytf c r7-y5 /
<br />Certificate of Occupancy l,
<br />Notes, Remarks, Etc.
<br />Rev. 08-0/-201 5
<br />atx^'c nrcntionc(l pfi)F-fly lin
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