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BUILD!NG. INSPECTOR RECORD <br />I <br />I <br />SITE.WORK DATE ID/S!G.COMMENTS OWNlrlR BtIILI)I.lR l)lll,CARA'l'ION <br />IhcrebyaffirnlunderpenahyofpcrjurythatImcxemptfron)lheContrack)N LicenseLawforthefollowingrcdson(S.c.7031.5 <br />llusincss rnd Prolession Code): Any City or County which requires a lrrmil to construct, aller, ihprove. dcrmlish or (-pat any <br />slnrclure. pri(tr &) its issuance. also requires the applicanl tbr such pernrit tr file a signeil statcrcnl lhat lE or she is licefl€d pursuanl <br />h thc provisions o[ thd Contractor's Liccnscd lrw (Chaptcr (r. Comrncncing with Scction 7(Xx) of l)ivision 3 ol lhe Business and <br />Profcssi()nsCode)orthalheor\heisetempttherefromandthehasisfortheullegedexenrption. Anyviolati(nrofSectimT0Sl.5byany <br />rpplicnntforifEnnitsubjectsthe rpplicanttoncivilpenillyoInotmorelhanllvehundrcddollnrs($5{x)). <br />_1. ar owncr ol th! profDfly, or my cmployecs with wagcs as thcir slc compcnsation, will do the work ard lhe strctw is mt <br />intended orofferedforsle(S('.?(X.{.BusinessandPmfessionsCuIc:TheConlmcbr'sLiccnsckwdesnollpplyloailownarof <br />rheprcpeny wlx)fuild\oritrrprovestlErcD,ilxlwlDdoessuchworkhimselforlErsell'orthroughhisorherownempbyees, <br />providcd lhat such irnproverftnts arc nol inlcnded or ollcrcd for sale. Il. howcvcr. thc building or improvcmnt is sld within onc )tr <br />ofconrpletiur, the Owner Builder will luve the burden ofpmving thal lE or she did fitr buill or impmve thc ptr)Fdy for the purFrc of <br />salc). <br />_1, as owner ofthe propcily, am exclusively contractin8 with licensd conlraclos to conslruct llE prcject (Sec. 7(N4, Busincss <br />ard Rulessi(llCode:TheContractor'sLicenscLawd(,esnotapplybanownerofpropenywhobuildsorimproveslhereon. <br />and who contrags lirr such projccls wilh a Contmclor(s) liccnsd pursuml ro lhc Conlractor's Liceilc [jw). <br />_l an) exempi utrder Section-, B. & P.C. fbr this reason. <br />\Y()RKl,llls' ( ()Nll'!lNSA l'l()N <br />t)[.( t.,\ItAl't()N <br />I hcrcby allirm under Pcnallyof periury onc o[lhc tollowing dccltrations: <br />_lhaveandwillnaintairraCertiticateofConselttuSelt:lnsuref(rrworkers'conrpensation,as FrcvidedforhyScctionlT00ofthe <br />Lrhor Codc, for lhc pcrformancc oflhc work lbr which thc permit is issucd. <br />_lhaveandwillmaintairworkers'compcnsrlioninsurance,as requiredbySecli(n3T00ofthcLaborCode,forlheperfomunccof <br />thc work tilr which lhis pcrmit is issu('d. My workcrs' conrlrcnsdion insurilncc caricr rwl grlicy nunrtrr ruc: <br />Policy Nunrber: Exptrcs: <br />_I ccnily that in rhc pcrLrmance ol thc work for which this pcrnril is is$uc(I, I shall not enrploy any pcrson in uny manner <br />s as to trcoilE subjecl to thc workers'cotrrpcnsrlior laws ofCalilbrnia. ard agrcc lhnt il l should bccom suhlcct to thc <br />workers' .onrlEn\rtion provi\ions of Sectiotr 3700 of th€ Latpr (bde, I shrll, fo(hwith comply with rhos pmvisions. <br />WARNING: Fdilurc to sccurc workers'compcnsation covcBgc is unlawful, and shall subjccl an cmploycr lo oiminal lrcMIi:s ud <br />crvil lincs up to one hundred thousatrd dollirs (Sl(X).(XX)), in rddition to the cosl of conrpensation, damges as provided for the <br />Section 3076 of the titx)r Code. intercsl and atbrcy's iees. <br />I,ICENSED CONTRA('T()R <br />DI]CLARATION <br />I hcrchy al lifln undcr pennlty ot pcrjury lhat I arn Iicensed undcr provision ol Chaptcr 1) (cornrrcncinS wirh Sccrion 7Un) oI Division ] <br />of the Rusrrcsr and Profcssions Code. afrl mv liccn\e is in tull lbrcc md eftad. <br />[-rccnsc \,".M.._ <br />CONSTRUCTION I,I.:NI)ING AG}]NCY <br />I hereby atlirm under pnally {)fperiury that lheae is a cotrslnrclinr leildilg agency tor the perfornunce ofthe work tbr which this Frnrit is <br />issucd (Scc. :1097, Civ. C.). <br />lcild(r's Nurc: <br />lrndcr's Ad(lress: <br />APPLICANT DECLARATI0N <br />I hereby affmr under penahy of perjury one of the following declarations: <br />Demolirron Permits-Asbestos Notification Federal Regulations (Tirle 40, Pan6) <br />_Required kiler of Nolification <br />_l ccnily that the federal regulalioN rcgffding asbestos renxrvrl rrc nd rpplicable k) rhis proicrr. <br />_l ceaify lhal I luvc read this applicalion and stalc lhal lhc ah)ve i[fornmlion i\ corecl. I agr@ to comply with rll City nnd County <br />ordir)atrccs atrd Strte liws reL[ilg to building corstrudi(n\ atrd hereby authorize representatives of this City and County b enler ulDn the <br />abovc mcnlioncd propcny for inslcction puqnss. <br />Applicxnt or Ag(il1 <br />P(mllec namc {print): <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 />lt/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputv Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />FINAL <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />Rey. 08-07-2015 <br />l)ale <br />-