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BUILDING- INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARA'IION <br />I hereby aflirin unds pcnalty of perjury that I m .xempt from the ContractoE Licmse Larv for the follorving ree)n (Ss.7031.5 <br />Businss md Prof*ion Code): Any City or County which requires a po'mit lo construct. alta. improvc. dmolish or repair my <br />struclure, prior to lts issuance, also requirs the applicmt for such pennit to filc a signed statemot that he or she is licmsed pursuMt <br />to the provisions of the Contractor's Licensed law (Chapltr 9, Cornrnencing with Sstion 7000 of Division 3 of the Uusins md <br />Prol-cssiotrs Code) or that he or shc is exempt lhsefrom od the bsis for the alleged eranption. Any violation of Seclion 703 | .5 by any <br />applicant for a pcnnit subjsts the applicant to a civil penalty of not rnore thm five hundred dollus ($500). <br />__1. m orvnq ol the pro[Efly. or my ernployee with wags s their sole conpssation. will do the work md the slrudue is not <br />intoded or offqcd for sle (Sa.7044, Busines md Profasions Code: The Contractor's Licsse law do€ not apply 1o m owner of <br />theprepefry whobuildsorimprovelhqon.edwhodo6suchworkhitnselforhmelforlhroughhisorheownemployee, <br />provided thal such impnrvmols ue not inlmdql or offqed for sle. lf. howwq. the building or irnprovernent is sld within one ,@ <br />ofcomplction. the Orvncr Buildq rvill hare the budo ofpoving thal hc or shc did nol build or improve the prepery for the purposof <br />sle). <br />l. as owns of thc property, an exclusively contractin8 with licenscd conlractoB to coNlruct the preject (Sec. 7044. Uusins <br />ild hofcssionCode:TheContractor'sLicenseLawdo6notapplylomosnsofpropmyrvhobuildsorimprovcslhssn. <br />and who conlEcts lor such prcjects with a Contmcto(s) licmsed pureumt to the Conlraclor's [-iceNe La\v). <br />I m exernpt unds Setion---, B. & P.C. for this rmon. <br />l)ale: <br />WORKERS' CO[IPENSATION <br />DECLARATTON <br />I hoeby allirm undcr penalty ofpajury onc ofthe following delruatiore: <br />_l havc md will mainlain a Cenificate of Coreflt to Self-lnsure for work6s' compssation. c provided for by S6tion -1700 of the <br />Labor Code. for the perfommce of the rvork for which the pfinil is isued. <br />__l haveanduillmaintainworkm compcmationinsurance,a rquiredbySetion-1700oftheLaborCode,forthepsfomaceof <br />the work for which this pemit is issued. My works compssation insurmce cmier md policy numts ue: <br />(.aricr:. <br />Policy Numbtr:- <br />---Expires: <br />I cefrify lhat iI the performance ofthe work which this perrnit is issued, I shall not employ any person in any mmner <br />$ 6 to b€come subjst lo the workds'compeNalion laws and agre thal if I should bccorne subj{l lo the <br />work6' lompmsation provisions of S6tion 3700 of lhe Labor conrply rvith lho* provisions. <br />WARNINC: !-ailure to s(ure rvorkm' compensation shall subjet m mplcyct to siminal Fnalti6 and <br />civil fincs up to one hundred ($l of rJmages o provided t)r the <br />Sstion 3076 oflhc Labor <br />D<<- lLlhtc: <br />DECI-TRATION <br />I hoeby aflinn undr pmalty of pejury that I m licosed undo provision ofchapts I (commocing with Section 7000) of Division 3 <br />of the Buins od Profcsiof,s Code. md my licmse is in full force ud effel. l <br />oLicensc <br />CONS'TRUCTION LENDING AGENCY <br />I hereby affrrm undo ;uralty o f pqjury that thqc is a construoion lmding agmcy for thc pafomance of the work for which this pernit is <br />issued (Sa. 3097. Civ. C.). <br />Lendq's Nme: <br />Lmds s Addrm: <br />APPLICANT DECLARA'TION <br />I hoetry aflinn undo pmalty ofpojury one oflhe following deldalions: <br />Dcmolition Pqmits-Asb6los Notification [redqal Rc8ulations (Tille 40, Parl6) <br />Rcquired lf,tt6 of Notifi cation <br />-l <br />cdtify that the fedsal regulalioN rqnoval are not applicable k) this projst. <br />_,1 ccflify that I have read this above infonnation is conect. I agr* to cotnply with all City and County <br />ordinances and State [,aws aulhorize reprBcntativ6 ofthis City and County to fltq upon the <br />above motioned prcpsty for <br />,\pplicant or Agenr <br />tPemrile trsmr (pri[t): <br />\rz lLl'd <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bfloorA/enVl nsu lation <br />Roof Sheathing <br />Shear Wall <br />Framing <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 />FINAL fzlrLlra '-/r*V) <br />Certificate of Occu <br />Notes, Remarks, Etc. <br />l)alc: