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BUILDING- INSPECTOR RECORD <br />Rev.08-0/-2015 <br />SITE.WORK DATE ID/SIG COMMENTS owNER lttJILl)UR t)Et,CARA'ilON <br />I lEreby affirnr under penalty of pcrjury lhat I am exempt from the ContrrctoD' License liw for thc following reason (Sd.70J1.5 <br />llusiness tftl Pro,tssi()f, Codc): Any City or County which rcquircs a fErmit h con\lruct, alter, irnprove, dermlish or rcprir any <br />slnrctrrre. prir)r to ils issuance. al-so rcquires the applicanl lbr such pmlil () fib a si8ncd stalemnl lhat he or she is liccNd pursuant <br />ro rhc nmvishns o[ lhc Contrach. s l,iccnsed lxw (Chapter 9. CommcncinS wirh Scclion 7000 ol l)ivision 3 ol the Busincss and <br />ProtcssionsCode)orthatheorsheisexemptthereliomandtlEbasislbrtlEllle8edexen)ption. AnyviolationofSectionT03l.5hyany <br />npplicrnrfornpcnnitsubjccrsrhe applicantroilcivilpemltyofnolnoreth{ilfivehundreddollilrs($5(x)). <br />_1. as owner ol lhc profEf,y. or my crnployccs with wagcr as lhcir solc compcnsation, will do lhc work and the stMlure is ml <br />irlerxlql or offcred tor ulc (Se.704.1. Busincss and Prcfesskus Cqle: TIE Conlrack)r's Licen\c lnw does nol apply lo an owncr of <br />thepoprny wlx)tNildiorimpmvestherur[adwhodoessuchwrrkhinrselforlrrselfortltrou8lrhisorherownemployecs. <br />pro\ idcd that snch irnprcve mnts de ml intcrded or olfcrcd Ibr sle. Il. howcvcr, thc building or improvcmnt is sld wilhin orc )ed <br />ofconpleti(n\ ttE Owrrer Builder will have thc burdcn ofprcvinS lhN lrc or she dirl not build r)r impn)ve thc pmpe(y for tle purF)s of <br />sale ). <br />_1. as owner of the pro|Erly, am exclusively contractin8 with licensd conlrack)n to.otrslruct tlE pmject (Sec. 7(N4. Business <br />and Pn)tissinrCode:'IheContracrrr'sLiccnseLawdoesnotapplyn)rtrowoerofpropenywhohuildsorimproveslhereol <br />and who conlracts for such prcjccls with d Coilracto(s) liccnscd pursuant to lhe Con[actor's Liccnrc Law). <br />-IanlexemntUBlerSectilln-'B,&P,c,ti,,thisrcasoD,l)atc:_ <br />tvoRKuRs' ('ot\tPENsA'iloN <br />DECI,ARATIoN <br />I hcrcby nllirnl undcr pcnrlly of pcrjurv onc ot lhc li)lhwing dcclarrri()nsl <br />_IhaveafllwillminlainaCcnilicateofConsenttrSelf-lnsureforworlers'conrlxnsation,as pmvidedforbySecti{)n3700oflhc <br />ht{tr C(,dc. for the pcrformarce o[lhc work lbr which thc pcrmit is issucd. <br />_l have and will maintain workers' conrpcnsali(,n itrsurance, as requircd by Secli()n 3700 ofthe kbor Code. for thc perfornurce of <br />rhc work ti)r which lhlr pcrnil is issucd. My workcrs' conqrcnsati()n lnsurilncc cafiicr and policy f,umtEr de: <br />Policy Nunrher: Exfics: <br />_l ccnily thnt in thc pcrli)rnunce of thc work for which this prnrit is issucd, I slull mrt cnrploy any pcrson i[ any muncr <br />so as to bc$rrc suhjcct lo lhc workcrs' conrpensal ion laws of Califomia. and agrce thal il l shotrld hccorE subjcct to thc <br />workers'coNlrnsationprovisionsofScctionlT00of(heLaborCode,lshall,fofrhwithconrplywiththosprcvisions. <br />WARNING: Failurc t) sccurc workcrs'compensation coveage is unhwful. and shall subject an emphycr to qiminul frcMlties md <br />civil fines up to onc hundrcd thousand dollars ($lU),((x)). in nddilion to lhe cost o[ compcnsdtion, darmgcs as providcd foa lhc <br />Seclion 30?6 r)frhe tihlr Cixle, interest and dtbmey s fees. <br />I)rlc:_ <br />I,ICENSED C()NTRA(]T0R <br />I)ItCI-ARATION <br />I hrR'by al lifln undcr r-nalty of pcrjurv thal I arn liccnsd undcr provision ol Chaptcr 9 (cornrtu'ncing wirh Sccti()n 7(Xn) ol Division 3 <br />of thc llusines\ rnd Prol'cssions Codc. ml mv liccnsc is in tull ti,rcc un(l tllcct. <br />l-iccnsc Nurnbcr' <br />CONSTRT'CTION I,I.:NDlNG AGI]NCY <br />I heehy allirm undcr p*nalty of periury that there is a consrructi([ lcodilg agercy l'or thc perf(]murEe ofrhe work fi)r which this pemrit is <br />issucd (Scc. 1097, Civ. C.). <br />Lctrdcr's Nnnlc: <br />I-cnilcr's A(l,Lcs\: <br />APPLICANT DECLARATION <br />I hwby aflm unrjcr penalty of perjury one ofrhe followinS dfr'lararions: <br />f)emolitiotr Pernlits-Asbestos Notificalion Fcdcral ReEUlations (T[le.l0. Pan6) <br />-Required <br />tf,llcr of Notification <br />_l cenili thrt the fe(leral regulxliuN rcgilditr8 ashcstos rcnx)vill are mt nllplicnble k) rhis proiecr- <br />_l cenify lhdt I lurve reid this applicalion and statc lhat lhe ntnvc infomation is corccl. I aSree to conrply wilh all Ciry and County <br />ordinaNes and Statc tiws rehtiilg to h!ilding constructio[ ilil herehy authorize rcpcsentalives of this City and County to cntcr ulrcn the <br />atDve mnti()ncd propef,y lirr inspecli()n purF)scs. <br />At)l)licurrt or Agrnl Date:- <br />l'cnnilft nan)0 (Dfint): <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVl nsu lation tt It ./2 <br />Roof Sheathinq Fltzlt{tu Nztliflaa *{., <br />Shear Wall tt <br />Framinq <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Jt/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />,lt, /^I t-/? <br />FINAL ff/b-/ftrL'0Utlltljt ,YJ <br />Certificate of Occupancy <br />Notes, Remarks, Etc.