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BU!LDING. !NSPECTOR RECORD
<br />Rev. 0B-07-201 5
<br />SITE.WORK DATE ID/SIG.COMMENTS owNt]R BUtt,t)t]R t)t:l,cAlrA'ItoN
<br />I hereby allirnr under penalty of pcrjury that I am exempt from lhe Contra.los' License Lrw for thc following rcasn (Scc.7031.5
<br />Busincss and Profcssion Code): Any City or County which requircs a Frmit h conslruct, rlter. irnprove, dcmlish or rcpair any
<br />s(ructrrre, pri()r k) irs issuancc. also rcquics the applicant tbr such pernit k, file a signed slalemnt lhat lE or she is liccnsed pua$anl
<br />to thr pmvisions of lhc Conlraclor's Liccnsed law (Chaptcr 9. Comrncncing with Scction 7(Xn of l)ivision 3 of the Business and
<br />Prolessi()trsCode)orthatlEorsheisetempttherefrcnrandtlEb&risfbrlheallcSedexentpti,n. AnyviolationofsectionT03l.5byany
<br />applicanl for ! pcnnit subjccts th€ applicant to a civil per)xlty of nol rmre lhun fivc hundrcd dollilrs ($5(n).
<br />_1. a\ owner ollhe prolEnv. or my cmployecs wilh wagcs as lhcir $lc compcnsation, willdo thc work ard thc strcturc is mt
<br />irlenrjed oroffcredforsdlc(Sa.7(N4,BusinessandPmfessiorsCodc:TheConlraclor'sLicenseL6wdoesnolrpplyloanownerof
<br />thepfi)pcny wlnbuildsorimprovesthersn,andwhodoessuchworkhinrsellorherselforthroughhisorherowncmployees.
<br />providcd that such imprcvcmnts dc rel intcndcd orollctud for salc. Il. howcvcr. thL huilding or itrprovcrmnt is sld wilhi, onc yctr
<br />of conpletion, lhe Owftr Buikbr will luvc lhc burden ofprcvin8 llH lE or she ditl xl buill or impmve thc pmfrc(y for tlE purtr)s of
<br />ulc).
<br />_1. ns owncr ofthe propcily, am exclusivel), contrilctinS with licetrsed contrrclors to conslruct thc preject (Sec. 7(X4. Ru\ine\s
<br />and Pblassrnl(i)de:'['heConrraclor'\Liceilseliwd(,esnorapplybanowncrofpropcrlywhobuildsorimpr)vcsthcrcon.
<br />and who crtrnrxcts lor such prr)iacls with a Conraactrr(s) liccn\c(l pursurnt kr rhc Coilrnctor's Liccnsc Law).
<br />-Ianrelcnrptundcrseclion-.B,&P,C,lirrthisreason,
<br />WoRKl.lRS' (l()MPtINSATI()N
<br />D1:CLARATION
<br />I hcrcby allirm undcr penaly of pcrjury one of lhc ti)llowin8 dcclarari()nsi
<br />_lhaveandwill nraintahaCertitlcdteofConsenttoSelt:lnsurcforworkers'compensation,as prrvidedforhySection3T00ofthe
<br />Lahor Codc, for lhc perlormncc ofthc work lbr which the permil i\ issucd.
<br />[2r]have and will mainrain workc6' compcillation inruiancc, as requiled by Scction 3700 oflhc tihor Codc, for rhe pedomh-c of
<br />lhc work tbr-which lhis permit is issucd. My workqs' compcnsation insurancc caricr affl [rlicy number ue:
<br />At-rz-riCQy. /-rr iCt
<br />_l cenity thar in rhe pcrlornunce of rhc work for which Ihis pcrmit is issucd, I slull not cnrploy any 1lrson in any nunfii
<br />so as lo bccorE suhjecl lo thc workers' compcNltion laws ofcalilbnlia. and aSrce thar if I slnuld hccorr- subjcct to thc I '
<br />workcrs' compensution provi!ions ofSection 3?00 oflhe Labo, Cbde, I shall, fonhwirh conply with thu* prcvisions.
<br />WARNINC: Failurc k) scurc workcrs'conlpcnsation covcrrgc is unlnwful. and shall subject an employcr to 6imir4l pcMltics and
<br />compcnsation, drrm8cs as(rrovirled for theIcivil lirrcr up to one hutulred thousand doll.rs ($100,(XxD, in rddition to the cosl of
<br />Sectt)n -1076 ofthe Latx,r Co(le, iil€rest an(l atk)mcy s
<br />Dut",-212 !1ll o l) ani g
<br />I herchy allifln und.r pcnalty of pcrjury lhat I arn liccnsd Chrptrx 9 {cornrnen.ing with Sccrion 7000) ol l)ivision l
<br />of rhc Busidcss and Prcfessions Code. md my liccnsc is in full lbre and effecr.
<br />I
<br />Licensc C2 Nurnbcr'
<br />tru",-.4:-L-51-q-(hnlruclor:.vi vi n1-S orq. r
<br />CONSI'RI,]CTION I,ENI)ING AGI]NCY
<br />I herchy attrnl undcr ltoalty of p€riury thai there is r construct ioD lcrxlLlS aScNy li,r I hc perfr)munce of the work tbr which tllis n€rrnit i\
<br />issucd (Scc. .1097, Civ. C.).
<br />Lcndcr's Nrrnc:
<br />[-cndcr's Addrcss:
<br />APPLICANT T'ECLARATION
<br />I hecby affml under penalty of pcrjury one of thc followinB declarations:
<br />Deft)lilion Permils-Asbestos Notiflcation Fcderal RcSulation$ (Title 40, Pan6)
<br />-Requted
<br />ktter of Notificdtion
<br />_l ceaify lhar lhe federalregularions regudinE xsb€sbs rcnrcval rre not applicahle k) this proFct.
<br />W U4r, ,nn I havc rcrd this application afil sratc thal th. above infomilion is core{. I ngre to comply with all Ciry and Counly
<br />ordirEDCes rnd Strle Laws reLtilg trt huildiDg constructi<u ord hereby autlDrize raprerilalives of this City and County to cnter ulpn the
<br />atx)vc nrcntioncd l}ropeny for t; ,_,2Applicsnt or i\gcnt
<br />l'rnDitec nanrr
<br />puqxlscs.
<br />c .S
<br />Q4-eu
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsu lation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framinq
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />ltrlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />/t
<br />F!NAL /,a/;zn nz W?r )
<br />Certilicate of
<br />Notes, Remarks, Etc.
<br />n,,,.rn",.u",, L,( r 5DQae.d[3 ,^,,',",, ll/(lZo
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