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BUILDING- INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG COMMENTS OWNI,IR ItUll,l)l.lR l)III,CARATION <br />I hereby affirnr under pcnally of perjury thal I m exempl fronr lhe Cu{raclors License I*w for the following rcason (Sec.703 1.5 <br />[rusrncss and Prolcssion Codc): Any City or County which rcquires a 1-*rrnit k) conslruct, altcr, irnprovc. dcrmlish or rcpair any <br />stnlcnlre.prior()its issuance.alsorequircstheafrplicantti)rsuchpernritt)tilcasiSncdslatemnl thatlrcorsheisliccnsd pursuant <br />o lh(' provisions of thc Contrdctor's l,rccnsed [-aw (Chapter 9, Comilrcncing wilh Scclion 7(XX) ol Division 3 ol-thc Busincss and <br />Profcssi(msCode)orthalheor(heisercnlplthereiromandthehasistirrtlEullegedexcnrption. AnyviolatiurofSectionT03l.5byany <br />Applicrnl for u lErmit subjecls the appliconl to n civil p.nahy ol not rmre lhan llve hundrcd dollors ($5U)). <br />_1. as owncr ol'lhc propcrty. or my crnployees wilh wages as lhcir solc cdrnpcnsali(]n, will do lhc work and thc slrlcture is not <br />iilcrxled or offered for sle (Se{.7(N.{, Business nnd PR)fesskrtr\ Code: The Contrnclor's Licensc [-aw does not apply rc aD owner of <br />thc p[)pcny wlx) buildr or irnprovcs lhcrdnr. aril wk) d(ts such worl hinrsell or hersell or through his or her owil cmpl()yees. <br />prolidcd thal snch imp(ov.rrcnls {c ml intcndcd (}rollcrcd lbr sile. II. howcvcr, t}E building or improvemnt is sold wilhin onc }rar <br />ofconl)lelidr, llrc Owner Buil(lcr will hnve the burden of provilg tlul he or Nhc (lid Dol build or impft)ve the pmpeny for lhc l)urF)se of <br />srle). <br />_1. ns owner oflhe proparly, rm exclusively contrecting with Iiccnsed conlractors to conslruct thc prcject (Sec. 70,14, Buriness <br />and [h)tesskn)Code:The(bntructor'sl-iceusel-awdoesilotapplytoanownerofpropertywhobuildsorimprovesthereon. <br />and who comracts for such projccls wilh a Conlmcb(s) licenscd pursurnr h tlE C(lntraclor's Liccnse t w). <br />-IamexemPtutrderStctilrn-'B.&I,.C.filrthisreason. <br />W( )RKI.IlLS' CONI I'HNSA'IION <br />I)ECt,ARATI()N <br />I hcrchy attrn undcr pcnalty of pcrjury onc of thc toll()wing (lcclffationsi <br />_lhaveiuxlwillnuintairaCe(ificatcofCofuscnlk]Self:lDsureforworkcm'compentation,as pnrvidedforhySectionJT00oflhc <br />Lntnr Codc, for the pcrforroncc ofthe work for which the pcrmit N issucd. <br />-l <br />have and will nrrintain wrrkers conrpensaliotr itr{lrrnce, n\hy Seclion 3?00 of lhc Uhor Codc. for the perfomr-c of <br />rhc *(nk li)r whtr lr lrcrmil is issucd.:4 My ilrxl lx)licv nuorhd ilc,ar/{ //a' ra/ /52€ <br />Policy ALl A 7 *a-o I os-ZD -2 <br />_l ccnity th6t in thc pcrfi)rnuncc of thc work for which this pcrnit is issucd, I shall not cmploy uny pcrson in any munncr <br />s as lo hecorE suhjccl lo thc workcrs' conrpensation hws ofcalifomia. and dgrcc that if I should hccorrc suhjccl to thc <br />worlers'conrFnsationprovi\ionsofSeclion3?00ofthet borCqle,lshall,fonhwirhcomplywithtlDsprcvisions. <br />WARNING: Failure to sccurc workers'compcnsation covcrrgc i\ uillawful. and shall suhjcct an cnrlhycr () dminal penalties lnd <br />civil liner up to one hundrcd thousxnd dollnrs ($l{X),(XXI), <br />Sectirnl 1076 ofrhe Latxtr Co(le, interest and attonEv s fee\. <br />iD rddition ro lhc damnges as provided for l\c <br />,r^,". -7"2a-2o <br />I hcreby aflifln undcr penalty ol pcrjury that I am liccn$'d 9 (commncing with Scdion 7fi)0) ol l)ivisio?rj <br />of thc Businrss aml Pnrlcssions Codc. and nrv liccn\c is in lull tbrce and clltct- <br />- ,.a-<< <br />Liccnsc Class: L Liccnsc J-33s <br />?? <br />I hercby atllrn) under Filalty of periury lhat there is a constnrcttlr leDdilg a8eocy fbr t he perfomance of the work tbr which this pemrit is <br />issucd (Sec. 3(197, Civ. C.). <br />LrNicr'" Nrnr.' <br />[rn,lcr's A,ldress: <br />APPLICANT DECI,.{RATION <br />I leNby aflm undcr penally of perjury one of the followinS declarntions: <br />Denulitior Pcrmits-Asbestos Notification Federal Rcgulations (Tirle 40, Paf,6) <br />-Required <br />lrtrer of Notifi.ntion <br />I cglify lhxt llE feJeral rcaulationr rcguding asbestos rcnx)val arc no( applicahlc b lhis pmiet.IT. L; <br />4 onif) rhal I have reail thi\ applicalion emd sralc that lhe abovc infomalion is corccl, I aSrE to comply wilh all City and County <br />ordiuarrccs and Stalc Laws rehting io huildiilg auth(,rize reprcscilliltives ()[this City and Coluily lo enter upon llE <br />atxrvc nrcntiontrl prrpcny lor inspcct <br />Applicunt or Agcnt <br />P(nrilcc name <br />u*",t, 7- 7 z/-?3 <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/Eneroy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />ltrlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputv Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />l.)^tL 2,e9l\ lt^"!r \q <br />F!NAL 91441+t - ?Arfi <br />Certificate of Occupancy \ <br />Notes, Remarks, Etc. <br />4l z Zl ?. o ,. 2NI.^, <br />+ <br />Rev.0B-07-2015 <br />. <br />Tftl )-l*+t'