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BUILDING. INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG COMMENTS owNt:R lrutl,Dt]t( l)ut,cARA't'toN
<br />I hereby affirn under penalty of perjury that I anr etenrpt fronr the (:ontraclos Licensc tjw for the following rcaen (5(.701 1 .5
<br />llusincss and Prolbssion C()de)r Any Cily or County which rcquircs a lErinil k) conslrucl, allcr. irnprovc. deralish or rcpair any
<br />slnrcture, prior k) its issuance. also requircs the applicaill fbr srch fEmit t() fih a sigilad slatemtrl lhat lt or she is licatrrd purjuant
<br />to thc nmvisions of the Conlractor's l-iccnsed lrw (Chaptcr 9. Commcncing wilh Scction ?(Xm ol Division 3 ol-thc Busincss and
<br />ProlcssiousCode)orlhatheoriheisexempttherehomandlhebasislbrtlrcalleSedexemptbtr. nnyviolatioilofSectionT03l.5byatry
<br />rppliclot for l permit subjects lhe npplicailt to a civil pendlty of nol more than llve hundred dollars ($5lx)).
<br />_1, as owncr ol thc profrny, or my cmployccs with wagcs ds lhcir solc compcnsation, will do thc wo,* and lhe lMturc is mt
<br />interxled oroffcrerlforule(Se.T044,BusincssandPrcfessknisC(xle:TheConlrrcbr'sLicenscL{wdocsnotspplylotnowncrof
<br />the pn)pny wk) huilds or inprows thcrm[ axl wlm docs such work hinrself or lErself or tlrough his or lrr owl enrployees.
<br />proYid('d rhat such improvcrEnrs dc 8n htcnded orolLrcd ft)r $le. ll, howevcr. rhc building or improvcmnt is sold wilhin one ycar
<br />ol conuletitu. the Owrrer Builder will hrve thc burden of provirrg thfll lE or she did ftn build or imprcve the pmtEny for thr puqnsc of
<br />sale).
<br />_1, as owncr ofthe propef,y, am exclusivcly cootrscling wilh liccnsed conlraclors 10 con\lrucl the p()jed (Sec. 7044, Businass
<br />arxl Pn)tl\si(nrCr)dc:TheContractrr'sLicenseLawdoe\notapplyloanownerofpr(!pertywhobuildsorinlprovesthcrcon.
<br />and who contracls for such proiccls wilh a Conlraclor(s) liccnNcrl pursuaot h thc Cootrlc(tr's l-iccnsc Law).
<br />_l anr exempt under Section-, B. & P.C. lbr this reason.
<br />Drle:_
<br />W()RKI,IRS' ( ( )IlI'UNSA'I l( )N
<br />t)E('t.,\R,\1 t()N
<br />I hcrchy atlirm undcr plnaly of pcrjury onc ot lhe lbllowing dcclarations:
<br />_lhoveuxlwillnuinlaina(c(ilicateofConsenlk)SelllDsuref(rrworkers'conrpensation,as pmvidedforhySccti(]n3700ofthe
<br />Lnk)r Codc. Ibr thc lcrformtncc ol-lhc work li)r which thc pc,mil is issucd.
<br />_lhaveandwillnraintainworke6'comp€Nalionirsurance,as requiredhySection3T00ofthetihorCode,fortheperfomurccof
<br />thc work lbr which lhis IErmil is issuql. My workcrs' conrpcNation insurnncc cmicr iuxl lnlicy numhcr trc:
<br />Policy /z/tr,/z-,.t
<br />j(l ('nily rhd
<br />,---7
<br />in lhc lrrli)r nnncc ol thc w(nk ,i)r whirh lhis l)ctrril is issuc(|, I shall not cnrpby uny pcr\,rn in dily nranncr
<br />so aslohcco,msuhjccllolheworkcrs'compcnsalioDlaw\ofCxliforniil,andil8rccthntifIshouldtacorrcsubjccttothc
<br />workers'coDrpensalionprovisionsofSectionlT00oftheLaborCode,lshilll,f(,nhwithcomplywithtlp*pruvisions.
<br />WARNING: Failurc (r securc workcrs' compensili()n covcrdgc unlawful, and shall suhjcct m cmploycr tr oiminal 1rcMLies Md
<br />civil llnes up to one hundrcd thousaM to the of conrpcnsalion. darmges fls provided for tha
<br />Secli()n 1076 of [jtDr Cqle. intercst fees.
<br />I hcrcby allirrn und('r pcnalt], of pcrjury lhat I arn liccns!-d Chaptcr 9 (cornrroncing wilh Scqion 70ff)) ol Division 3
<br />o, rhc Bu\ines\ and Pnrtrssions Codc ml nrv liccnsc is in tull fircc and cllict
<br />I 7l,iccnstr Nunbcr:
<br />I hercby aflrm undcr Fnalty ofpedury tlrat there is a constnlctiur lcndirg ageilcy for I
<br />issu(d (Scc. .11)97, Civ C.).
<br />Lcndcr's Nxmc:
<br />perfi)matrce of thc work tbr which this pemrii is
<br />Ixn(lcr's A(l(lrcss:
<br />APPI-ICANT DECLARATION
<br />I tmby uffmr under penalty of perjury onc of thc following declardlions:
<br />Demolirion Permils-Asb€rtos Notification Fcdcral ReSulations (Tille,l0, Pan6)
<br />-Requircd
<br />lf,lter of Notificalion
<br />_l ocdily lhat tlE federal rcsulatiorE rcgarding asbcslos rcnpval arc Dot applicablc to rhis pmlxl.
<br />nnd slrle lhal lhe rh)ve irrfonralion is correct. I tgrcc lo conrply wilh rll City and Counly
<br />constnrcti(nr. ilil herchy authorize representntives of thls City and County to entcr uF)n llE
<br />Applicf,nt or Agcnt
<br />['rrrDiler
<br />lo
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsu lation ,.1,,
<br />Roof Sheathinq 1 dzt laoTr,
<br />Shear Wall
<br />Framinq
<br />lnsulation/Enerqv
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />[t/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />I
<br />,A
<br />FINAL ttll/zo Dfl lt i)
<br />Certificate of Occupancy .l
<br />Notes Remarks Etc.
<br />Rev.0B-07-2015
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