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BUILDING- !NSPECTOR RECORD <br />Rev. 0B-07-20.15 <br />SITE.WORK DATE ID/SIG.COMMENTS owNllR ltt,ILDl.lR l)rLCARA't IoN <br />I hereby affrrm under penalt,v ofpcrjury thai I an) cxenrpl from lhe Ct)ntr0ctoN l-icense Law for the following reason (5(.7031.-5 <br />llusiness and Prolbssir)n Codc): Any City or Countv which requircs a lErmit h conslrucl, aller. irnprovc. dcmolish or rclair any <br />stnrcture. prior to its issuance. rNo requires the applicatrt t'or suclr pemrit to file a signed slatemnt that lrc or she i9 licetrerl pursuant <br />Io lhc previsions of tkL Contraclor's I-icensed liw lchaplcr 9. Cornrncncing uilh Scclion 7000 ol Division J ol the Business and <br />Prol'es\ioilsCode)orthathcorthei{exempttheretiomandtlEba\istbrtlEllleBedexemptidl. AnyviolarionofSecri(,n703l.5byBny <br />rpplicxnt [or a pnnit subjccls lhe applicanl to n civil pe[rlty of not more thiln llvc hundrcd dollars ($5(X)). <br />_1. as owncr ol'lhc prolf,rtry, or my cmployees with wrgcs aN their solc cornpdnslli()n, will do the work and thc structurc is mt <br />intenr.lctl orofferedfi)r$lle(Se.7044,BusircssrndProfes\knrsCode:The(inrlrnctor'sl-icenseLawdoesnotlpplybanownerof <br />thepff)pef,y whobuildsorimprovcslhemrlmdwhodocssuchworkhimsclforhcrsclforthroughhisorherownemployees. <br />rovid.d that such improvL'rmnts dc not intcnded orolltrcd l'or slc. Ill howcvcr, thc buildiog or jmprovcmnt is sold wilhin one ycar <br />of conlrkrion, lhe Owrcr Builder will have the burdetr of p()vir8 thilt he or she did ftn build or inrpnrvc thc prrJrny for tlE purfrs ot <br />$[d ). <br />_1. as owner of the pff)pcrly. nm exclusively contril(tins with licensd conlraclors to cotr\lruct the p()jcct (Sec. 7(H4. Business <br />and l\,tlssi(nlCode.ThcCi)ntrrc()r'sLiceuscLawdoerflotrpplybanownerofpr()pertywhobuildsorlnrprovexthereon. <br />ilnd who conlrncts litr such pr()iccts wilh a Conlract(,r(s) liccnscd pursuant h thc Ci)nlrlclor's Licensc Law). <br />_l rnr exempt utrder Sccti(,n-. B. & P.C. tbr this rcas(nl. <br />I)ste:_ <br />W()RKI.:RS' C()I\1PT:NSA'I'I()N <br />DECLARATIoN <br />I hcrchy allirm undcr f,cnnlry of pcr.jury one of lhc li)lk)wing dcclarationJ: <br />lhavcandwillnlaintainaCcililicateofCooscnlk)Scll:lDsurefrrrwrrkers'conrpcrrsrtion,as provirledfi,rhySecltr)nJ700ofthe <br />l-x[)or (lxlc, for thc pcrlitrmancc ol thc work lor which lhc pcnnit is issue(|. <br />_l lravc and will mairilain worke6' compensation irsurance, as required by Sectioil J700 of lhe Labor Clodc, fi)r the perfomme of <br />thc work lbr which this pcrnrit is issucd. My workcrs' conDcnsalion insurancc crricr iftl lDlicy numbcr dc: <br />( <br />Policy Nunrbefl Expires: <br />_l ccfity that in tbc lErlarnuncc of thc work fitr which this ocrmit is issucd. I shrll not enrploy {ny pcrson in aoy n]unncr <br />so aslohccorrcsuhjccttothcworkcrs'cotrrpensllioDlawsol'Crlifonria,aDdhsrcclhrlillshouldbccortusuhjccttothc <br />worlcrs' conrlEnsiltion provisions of Section 3700 of thc t,abor C'ule, I shall, fonhwith conrply wilh tlD* pruvisions. <br />WARNINGT Fuilurc to sccuru sorkers'compcns{ion covcruge is unlawful, and shall suhjcct an cmploycr n) cminal 1*mlics md <br />civil fines up to onc hundred lhousand dollars ($l(X),(XXD. in addilion to the cost ol cornpensation. darnrgcs ts providcd for the <br />Section 1076 of the titxrr Cixle. nxerest and atxrnry s fees <br />t)stci- <br />I,ICENSEI) CONTRA(:TOR <br />DECLARATION <br />I hcrcby alljrm undcr p!nalty ol pcrjury that I am liccnscd undcr provision ol Chaprcr 9 (cornmencing wirh Seclion 7(X)0) ol Division 3 <br />of rhc Business and Profcssi()ns Code. md mv liccnsc is in llll tbrcc ilnd clicct. <br />Liccilsc Class:_Licefuse Numbcr: <br />CoNS'I'II('C'TION I,I.]NI)ING AGI.]NCY <br />isrucrl (Scc. .1097. Civ. C. ). <br />l,cnJcr's Nrnrc: <br />APPI,ICANT DECI,ARATI()N <br />I hercby affim under pcnalty ofperjury one ofthe followinS declaration$: <br />f)enrolition Pernrits-Asbesbs Norification Federal Regulil(ioDs (Tirle 40, Part6) <br />_Required If, lter of Ndificalion <br />_l cef,ity that tlE fcderalrcSulations rcgtrdin8 asbestos renmval lre not applicrhlc k, this prcirt. <br />_l cenify that I have rcad this application arxl slatc thal lhc above infomtion is corccl. I agE to comply wilh all City and County <br />ordirunces and State ljws rclatiE b building constructbn, ald hereby autkrize rcpre*Natives of this City and Co!trty to enter ulrcn tlE <br />atx)ve mcnti()ned prope(y li)r lnspcction purF)ss. <br />Applicnnl 0r Aecilt Sisililluft <br />Prmiltce name (pinl):- <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVl nsu lation I <br />Roof Sheathinq U/zZ/zi .--tffitr ) <br />Shear Wall <br />Framinq <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />[Vlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />^F!NAL 7 'Ztr / z-o .zlX/t .// / <br />Certificate of <br />Notes, Remarks, Etc <br />kndcr's Addrcss: