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BUILDING. INSPECTOR RECORD <br />t:lev 0B'()7-201 5 <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUII,DER ])I'I,CARA'I'ION <br />I hereby rfllrm under penolty of periury that I flm exempt fn)m the Contrack)rs License l-aw for the foll()wing rensn (Sec.7oll.5 <br />Business antl l,rofcssion Corle)r Any City or County which requires a fErmii to (rnstruct. fllter. improve, demlish 0r reprir rny <br />structure. prirrr kr its issurncc. also rrquires the apllicrnt for such Frmi( k) file a qi8ncd stilemnt rhilr lE 'rr sb ir liceEe.-d pursuant <br />ro rhe pnrvrsnns of rhe Conrrilcr(tr s l.icen\ed Law {Chaprer 9. Commencing wirh Secrion Trxx) of Diririrr'ri.r r}rhe Bris)ne<s antl <br />Ptr)fessionsCode)ortharheorsh€isexempttherefiomandthebasisfortheallegcdexempli{)n. AnyviolationofSecliooT0lf.5hyany <br />applicflntforapermitsuhiectsthe applicanttrracivilpcnaltyofnotm)rethanfivehundre(ldollars($5(X)). <br />_1. as owner of lhe n()perty. or my empklyees with wages as their sole cornpensation. will (lo the Nork md the stNure is nor <br />inten(led oroffcre(lforsale(Sec.T0.l4.BusinessrndhofessionsCode:'[he(inlraclor'sLicenqeLawdoesnotapplytrranou'nerof <br />thepfi)peny whotiliklsorimpmvesthercon.an(lu'h)does\uchworkhinrselforhcrsclforthr()uShhisorherowncmpl()yee\. <br />provide(l that such inrprovetrrntq ile f,ot iilended or offrre(l f(x qlc. If. hrwever. the tuikling or irrrprrvermnt is sokl within one yerr <br />ofcompletion. the Ou'ner Buiklcr sill lulE the fuftlen of ptr)ving lhal he or she rlid not huikl or improvc the pn)lEf,y for the purFx)seof <br />vrle) <br />_1. as owner of the pft)peny, am exclusively conlrilcting with Iicensed contrnctors k) construct the pmiect (Sec. 7{).14. Business <br />arl PnrltssirnCode:'lheConlrachr'sLicensel-awdoesnotapplykranownerofpropertywhohuildsorimprovesthereon. <br />rnd who contracts for such projects with a (hntracktr(\) Iicensed pursuanl t) the Contrachr's License Lflw). <br />-IaDrexen]plUndersec(i()n-.B,&P'C,forthisreason'l)alr: <br />\YoRKIRS' COI\ITI,NSAI ION <br />DI,CI,ARA I'ION <br />I hrrehy nffirm un(ler nenxlty r)f periury r)ne of the folhwing dechrrtirrnr: <br />_l haveand*ill maintainaCenifrcaleofConsenlloSelf-lnsuref()rworker\'compensntion,as pmvidedforbySectionST(nofthe <br />L1h)r C(xle. f()r the p€rfonmnce ofthe work frrr which the permit is issued. <br />_lhaveandwillmnirtrainworkcrs cr)nrpensati()nin\urrnce,as requirc(lhySectir,n-17(X)ofthel-ahorCode.fortheperformanceof <br />the u)rk frrr which thi\ perrnit is issued. My wrtrkcrs conrpen\ation insurxnce crrier and F)licy nurnber xre: <br />Policy Number: Expires: <br />{ .cnrfy rfrrt rn tlr Jxrfirrnrnce '!fthe urrk fnr which thi\ ncrrir i\ rs.ucd. I .h:'ll nr{ crDlrloy any per{r)n in rny m:rnncr(r rs to hccore suhject rr! rhe sr)rlcrs comlpnsati(tn liws of(:alilbrnia. rnd rgrce thrt if l \hould hecome suhiect o the <br />worker\'conrpen\atir)nprovisi{)nsofSectionl?(X)ofthelihrrCode,l\hall.fo(hwithcornplywiththos.pfl)visions. <br />WARNING: Faifure h rcure workers'compensilti()n covernge is unlrwful, ind shall suhject an empk)yer h qiminal JEnalties rnd <br />civil finer up h one humlrctl thou\and (krlhr\ ($l(x).(xx)), in rtltlition to thc ro{ of damnges as provided for the <br />Sectiiln .1076 ilf thr l.ahtr (ixle. inrere\r and att'mv's feer:__--?? <br />u"r", / -Li - ),o Apptr*nr: -4 <br />o <br />I herehy affirm under pcnalty of periury that I am Iicensfll under provisirn of Chapter 9 (comnEncing wilh Section 7(XX)) of Division -l <br />of the Business an(l P()fessions (i)de, md my license is in full force and effect. <br />[-i.en\e NU 3 c <br />l)ate: /-)l - >-s (imtra(lor -2 <br />I herehy rffirnr under lEnahy of periury thrt there is a construction bndinE ngency for the lErformance of lhe work for which this pcrfiit is <br />i\sued (Sec. .1(X)?. Civ. C.). <br />[-ender'\ Nnilrei <br />Lrn{irr'\ A(ltlrrs\: <br />APPLICAN'I' D1-CLARA'I'ION <br />I herehy afthrn unrler penalry of periury one of the folkrwing declarat ions: <br />Denxrlition Permits-Asltstr)s Notificfltion Federal Regulrtions {Title 40, Pa(6) <br />-Required <br />l.etler of N(nification <br />renrrvrl are not ilpnlic:rhle h lhis projecr. <br />rh)\e infi)nnnti(rr is corrcct. I lgree to conlrly wfh rll ('ity rn(l County <br />hcrthy repre\enlrtives of this ('ity nnd County (o enter ufx)n the <br />alx)ve,renti(ined pr)peny firr inspection purfx)se> <br />Appllcsnt or Agent Signelure: // //->/- <br />I'rmrilrr iliillr {prinO:H)n-tz;rr) <br />l)nlr >a) <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/Vent/l nsu I ation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsu lation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />lVlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />FINAL 4tql%o nt \t*t,titt <br />Certificate of Occupancy U e <br />Notes, Remarks, Etc <br />I 'tz?) <br />Os ncr: