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BUILDING. INSPECTOR RECORD <br />Rev.08-07-2015 <br />SITE.WORK DATE !D/SIG COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby allirm undcr penalty ol Frjury that I anr cxcilrpt ftom lhc Conlraclors' Liccnsc [aw for lhc following reason (Scc.7031.5 <br />BustDcss aNl Prolession Crxle): Any City or County which rcquircs a Jrcmit lo conslrucl. altcr. irnprove, dcmolish or rcJnir uy <br />structurc, prior lo ils issumcc. nlso rcquircs ihc apJ,liqnl for such [Ermil lo filc a siSncd slatcmf,t that hc or shc is liccnsd pursumt <br />k) lhc Jrovisions of llE Contraclor's Licensed Law (Chapter 9. Comtrrcncing with Scclion 7000 of Division 3 of the Busircss md <br />ProfcssionsCodc)orthathcorshciscxemptthcrefromrndthebasirforthcallcgcdcxcmption. Anyviolulio[ofscctionT03l.5byany <br />applicantlorapcrnlitsubjcclsthc 0pplicanlhacivilpcnaltyofnotmolcthmfivchundrcddollus($5url). <br />_1. ils owNr ol-lhc proJrcny. or nry cnrployccs with waScs as lhcf \olc coilllEnsalio[. willdo the worl and lhe stnEtuc is rnt <br />inlcndcd oroflcrcdli)rslc(Ser.7()4,l.Busincssandltotcssk)nsCodc:'l'hcConlracbr'sLiccnse[nwdocsDolapplytoanowncrof <br />thcproFrly whobuild\oriiurovcstlrcBntadwhodoessuchworkhintsclforhcrsclforthrcughhisorhcrowncmployces. <br />provdcd that such improvcnrcnts arc not inlendcd oroflbrcrl for salc. I[ howcvcr. thc buildiog or in]provcnrcilt is sold wilhif otrc ]Ee <br />ol conlplction. lhc Owncr Buildcr will have thc budcn ofproving that hc or shc did nol build or improvc lhc pmIrcfly for thc purJx)s of <br />$lc) <br />__1. as owncr ollhc prcpcny. atrr cxclusivcly conlrilcting with liccn$d conlraclors k) c()nslruct thc pmlrt (Scc. 7044. Busirrss <br />dnd ftofcssiorCodcrThcConlractor'sLiccnscLawdocsnotapplyk)anowncrofprolrcrtywhobuildsorimprovcsthercon. <br />and who contracls lbr such projccts with n G)nlrdctor(s) liccnscd pursuant to thc Conlrucbr's Licensc Lflw). <br />_l am cxcrnpl undcr Setion-. B. & P.C. for lhis reapn. <br />Drte:-- Omer:- <br />WORKERS' COMPE{SATION <br />DECI.AEAIION <br />I hercby alTirm undcr fEnalty of pcrjury one of thc following deluat ions: <br />_l havc and will rointain a Ccnifrcatc of Con*nt to Sclf-lnsurc l<)r workc.s'compcnsalion. as Frovidcd for by Scctbn 3700 of thc <br />tibor fue, for thc pcrfomncc of the work for which thc permil is issucd. <br />thc work li)r which lhis pcrillil is issuc\l. My workcrs cotrrl)cnsilti{rn iosurulcc can'icr rrxl l)olicy nunrh(r ilrci <br />Policv Numbcr: Exnircs: <br />_l ccaily lhat iil thc fErlbilmncc olthc work for which this pcrmit is issucd. I shall nol cmploy any FErson in any manncr <br />so as lo bcconrc subjcct lo lhc workcrs'compen$lion laws ofCllilbmia. imd agree thut il l should bcconr subjcct lo thc <br />workcrs'cotrlpcnsationprovisionsofScction.lTfi)oflhctatnrCodc.lshall.fonhwithLrmplywilhthospovisions. <br />I{ARNING: fiilurc to scurc workcrs compcn$tion covcragc is unlawful. and shall subjcct an cmploycr b ffirninal Fnaltics and <br />civil fincruploonchundrcdthousdnddollars($l0O.0m).inaddiliontothccostofcompensation.danugcsasprovidcdforthc <br />Scctiril 307(r ol lhc l-ilt$r C-odc, inlcrcsl and altorncy's lbcs. <br />Dote: <br />- <br />Appliont: <br />LICENSED CONTRACTOR <br />DECI,IIRATION <br />I hereby affirm undcr Jrcnalty of fErjury that I am liccnscd undcr provision ofChaplo 9 (conrnrcncing wilh Scclion 70fi)) ofDivision 3 <br />of thc BusiDess and Profcssions Codc. arrl my liccnsc is in full forcc and cff(t. <br />Licensc Class <br />Dale:- <br />Nu illhcr. <br />_ (-onlrarlor: _ <br />CONSTRUCTION LF]]\DING AGENCY <br />I hcrcby affirm undcr lEnally of JErjury that thcrc is a conslruclif kndin8 a8crcy for lhc pcrfortMcc of lhc work for which this Frmit is <br />issucd (Scc. 3097. Civ. C.). <br />lrndcr's Addrcssl <br />APPLICAM DECLARATION <br />I lmby alfinn undcr penalty of pcrjury onc of thc folkrwing dcclaralions: <br />Dcmolition ['crmits-Asbcstos Nolification Fcdcral Rcgulalions ('l illc 40, Pan6) <br />-Rcquircd <br />lxllcr of Notilicalion <br />_l ccnify th{t thc lcdcralrcgulalions rcgitrding rsbcstos reff)vrlarc nol applicablc to this projccl. <br />__l ccnify thal I luvc rcad this applica(ion od stale that thc atnvc inlbrnutknl is correct. I ogr@ to comply wilh all Cily trnd County <br />ordindnccs and Slalc ljws relating to building construction. illd hcrcby aulhorize reprcsentalivcs ofthis Cily and County lo cntcr upon the <br />ntnvc rEnIioilcd pmpcny for inspection purposcs- <br />Applicfl nt 0r,\gcDl Sigualurcl Dsle:_ <br />l'(rnrilee notrre (prinl): <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenVl nsulatio n <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />I <br />FINAL /.t*/ent ^r^Adt I <br />Certificate of Occu <br />Notes, Remarks, Etc. <br />kndcr's Narc: