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BUILDING. INSPECTOR RECORD <br />Rev.08-07-2015 <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcrchy rflirm undcr pcnalty of perjury lhat I anl cxcmpt from thc Coltracbs' I-iccnsc law tor lhc following rcamn (Scc.7031.5 <br />Busincss and Profession Codc): Atry City or County which rcquires a lEmrit to construcl. aller. improvc, dcnrclish or rcpair my <br />structurc. prior to ils issuancc. also requircs thc applicant for such lrcrnit to filc a signcd stalcrrctrt thal hc or shc is liccnsd pu,suel <br />to thc [rovi\rons of the Contractor's Liccnscd hw (Chapter 9. Comncing wilh S(tion 7000 of Division 3 of thc Busircss ard <br />ProfcssionsCodc)orthathcorshciscxcnDtlhcrcfromandthcbasisfor(hcdlcScdcxcnrplion- AnyviolationofScctionT0Sl.5bytrny <br />ilpplicunl lbr a pcrmit subjsts thc upplicant to a civil penalty of nol morc thnn fivc hundrcd dollus (5500). <br />__1. as owncr oflhc proFrcf,y. or illy ctrlphyccs with wrges as thcir solc conrlrcnsrlion. will do thc work md the strctrre i\ nol <br />irilcndul or olltrcd for salc (Scc.7044. Rusilcss an(l Prolcssions Codc: 'I hc Clonlr{clor's LiccDsc Larw docs not apply k) an owncr ol' <br />thcproprly whobuildsorirnprovcslhcrcon.andwhodocssuchworkhinselforhcrsclf()rlhroughhisothcrowncorpkryccs. <br />pr(,lidcd lhilt such improvenrcnls arc rct irlcndcd orollirrL{ for salc. lt. howcrer. thc huildirg or irrprovcrent is sold within onc yqlr <br />ol conrflction. lhc Owncr Buildcr will hnvc lic burdcn ofproving thal lrc or shc did not buikl or improvc thc prcpuly for thc purfns of <br />$lc). <br />_1. as owncr of thc pmpcrly. anrcxclusivcly contracting wilh liccnsd conlracbn to construd thc projccl (Scc. 7(X4. Busrrrcss <br />rnd PmlassionCoderThcContracbr'sLiccnscLdwdocsnolapplyloanowncrofproFrtywhobuildsorirnprovcslhcrcon. <br />and who contracts for such froFcls with a G)ntraclo(s) licenscd pursuant lo thc Contraclor's Licensc lrw). <br />-lamcxcmptundcrSstion-,B'&P.C'forthisIedson'l)illcl Orvnor: <br />WORKERS' COIIIPENSATION <br />DECLAR TION <br />I hcrchy nllirnr undcr pcnalty ol Nrjury onc (rf thc li)llowing dcclarations: <br />_lhuvcatrdwill mainlainrCcflillcalcofConrcnlhSelf-ltrsurclbrworkcrs'contrcnsation,as providcdfirrbySeclion.lTUloflhc <br />Labor Cfilc. for the perfomuncc ofllE wo* lor which thc pcrmit is issucd. <br />_l havc and will mainlain workers' comFnsatt l insurarce. as rcluircd by Scction -1700 of thc kbor Codc, for the pcrfornurcc of <br />thc work for which lhis perrrrit is issuc{. My workcrs' com;renslion insurance cMicr ud fnlicy numbcr ec: <br />ttrlicy Nuilhcr <br />_l ccnify th.rt in thc lErformuNc of lhc work lbr which this pcrorit is issucd, I shall not cmploy {ny lErsoil iil any rtunncr <br />so fls k) hcconlc subjccl to lhc workcrs' conrpcnsation laws ofCalifomia, and agrcc lhat if I should bcconrc subjcct to thc <br />workcrs' conrpcnsation provisions ofSccti(nr l?U) ofthc ljtnr Codc. I shrll, li)f,hwilh mmply wilh lhose pmvisions. <br />WARNINC: Failurc lo scurc workcrs'conrpcilsatiorl covcrage is unlilwlil. and shall subjcct an cmploycr lo cririlinal pcoilltics rnd <br />civil liDcs up lo one hundrcd thousantl dollars ($l()().(XX)). in addition lo lhc cosl o[ cornpcnstrlion. danmgcs as providcd li)r thc <br />Scclxn J076 ol llrc Litnr G)dc, intcrcsl and allorilcy's lccs. <br />Applicont: <br />IJSEN@-CQNIEACIOE <br />DECI.AMIIQN <br />I lk.rchy aflirn urdcr lrcnalty of Frjury that I ant liccnscd undcr prcvision of Chapler 9 (corrmncing wilh Setion 7000) ot Division 3 <br />of lhc Busincss and Prolbssions Codc. axl nty liccnsc is in full force ard cffel. <br />l.itcnsc <br />lhlc: <br />Nunrrur: <br />CONSTRUCTION LENl)IN(; A(:ENCY <br />I hcrchy allirm uMcr Frcnulty of Frjury lhal thcrc is a conslruclion lcndinS a8crcy lbr lhc pcrfonnorce of the work for which this IErrilil is <br />issucd (Sec. 3097. Civ. C.). <br />[rndcr's Nam: <br />[-cntlcr's Addrcss: <br />APPI ICAM DECLARATION <br />I lucby aflirm under pnalty of pcrjury onc of thc lollowinS dcclarations: <br />Dcmolition Pcrmils-Asbestos Notilicalion Fcdcral Rcgulalions (Titlc 40. Part6) <br />-Rcquircd <br />Lcttcr of Notitication <br />_l ccdify thut thc tbdcralrcg!lalions rcgffding trstEstos rcmvalde nol applicrlblc to this projffil. <br />_l ccrtify lhut I have rcad this applicaliol ud statc thal thc atnve inforDulion is coftcct. I aFrrc to conuly with all City and County <br />ordinances and Strlc [aws rclatilg to building coDslruclion. drd hcrcby authorizc rcprcscnlativcs ofthis City and Counly to cnler uJDn thc <br />ltnvc rrcntioncd propcny for inspcclion purfbscs. <br />Applicml or Agol SigmtuR: Drle:_ <br />Pemlle lrme (orint): <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVl nsu latio n t. <br />Roof Sheathinq 7/tf/za,tt t rffiltt I <br />Shear Wall L <br />Framing <br />lnsulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />lvlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />il <br />F!NAL 1/z <br />"/u7t) <br />!ffir <br />Certificate of Oc <br />Notes, Remarks, Etc <br />l)rlc: