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I <br />BUILDING. INSPECTOR RECORD <br />Rev.0B-07-2015 <br />SITE.WORK DATE ID/SIG.COMMENTS OWNIIR llt,ll,l)l:R l)lll-L-,rRA'f lON <br />IherebyaffirnrunderpenallyofperjurythatIanrexemptfronrtheContractoD Licenseljwforthefollowingrea$n(Ss.7031.5 <br />lrusincss ilnd Prol'cssir)n Codc): Any City or Countv which requircs a pcflnit l() conslruct. allcr. irnprovc. dcrnolish or rulair any <br />stRrcture. prior k) ils issurnce. also requircs the rpplicant tor sucfi p€rnlil (, filc a sigDed slaternetrt lhat lE or she is liceNed pursuant <br />to (hc previsions ol'rhh ConlrActor's Liccnscd llw (Chaptcr 9, ComrnencinS wilh Scction 7(X) ol l)ivision 3 ol'lhe Busincss and <br />P()fcs!iotrtCode)orthrthcorsheisexempttherelionraDdthebasislirrtlrcullegerJexenrptioD. AnyviolatimofSeclionT03l.5hyany <br />ilpplicnnl for a pcrnit subjects lhc applicant to r civil pcrlrlty oI not ilFre lhrn fivc hundred dollrrs ($5{x)). <br />_1. as owncr ol rhc pro[tfly. or my employces with wages as lheir $lc cornfEnsili()n, will do the work and the slreluc is mt <br />iilcrf,lql orofferedforulc(Ss.?Ol.+,BusinessandPmfcssionsCodc:ThcConlrncDr'sLicen*Lawdesnotapplytoanownerof <br />the prc[Ef,y wlm t{ilds or ir{rows thermtr ilxl who dcs such work hinrself or hers.lf or lkouSh his or her owil emrloyees. <br />proYided rhat such impovcrrcnts ae mt inlcrdcd or olTercd lor sk. Ili howcvcr, lh. buiHing or inproverrnl is sU within one yeil <br />ofconrplctirl thc Owrrcr Builder will have the burdcn ofpreving lhat he or she did not build or impmve the pmFfly for lhc purpoE of <br />salc). <br />_1, as owner oflhe [opcily. am exclusively conlracting with licensed conlr(ck)rs t) conslruct lhe projcct (Scc. 70.1.1, Business <br />arxl PrrtlrsitlrCrxlcrTheCoiltraclor'\l-icetr\eLxwdoesnotapplytoan()wnerol'propcdywhobuildsorimpr(,vesihereoil. <br />and who conlricls for srch proicls with a C()ntrrct)r(s) liccnscd pursurnl lo lhc ContrActor's Liccnsc t w). <br />-Ianrexemptundetseclion-.B,&P,c,forthisreasoil.l)ater- <br />WORKI.IRS' ('Oi\l PIINSA'Il()N <br />I)I]CI-ARATIoN <br />I hcrchy rll'irm undcr trrrrltv of pcrjurv onc {)l th.' lolh)wing (lcclarations: <br />_lhaveardwill nuinlainaCertificateofconsenttoSelFlNurefo.woflers'compeNalion,as prcvidcdforhySection3T00ofrhc <br />Labor Codc, for lhc lErformrcc of thc work Ior which thc permit i\ issucd. <br />_l havc and will nrainrlio workers compensation insurance, as rcquired by Scclion 3?00 ofthc trbor Codc, for thc JErfomN of <br />thc work lbr which this pcrmit is issucd. My workcrs' conrpcnsation insuruncc crfficr iuxl lblicy numhcr ilc: <br />Policy <br />_l ccnity that in the lEribrnunce of thc work for which this pcrmit is issucd. I shrll not employ any 1rcrs<rn in any manner <br />$ as to bccorE suhjcct to the workers' compcnsation laws of Californir. and agree thlt if I slbuld tEcorE subject to thc <br />worliers' conrJensation provisions of Scction 3700 of the trbor C'ode, I shall. fonhwith conrply with thos provisions. <br />WARNING: Failure to scure workers'q)mfEnsali()h covemge is unlawlll. rnd shall subject ro empbyer k) qimindl lE@ltics md <br />civil finesupbonchundrcdlhousanddollnrs(SI(X),UXD.inaddiriontothecoslofcompensation.damgcsasprovidedforlhc <br />Section 3076 ofthe ljtx)r Cqle, interesl snd albrrEy's fces. <br />Datc:_ <br />I,IC-ENSED CONTRACTOR <br />DECLARATION <br />I hercby al'llfln undcr pcnahy of perjury tha( I am licen*'d under provision ol Chaprcr 9 (comrencing wirh Section ?fflC) ofDivision l <br />of the Busincss ancl Prcfcssi()ns Code. affl nly license is in full forcc and ctilct. <br />[-iccnsc Nunlrr: <br />l)ale <br />- <br />Conlmclor: <br />CONS'TRI.ICTION I,ENI)ING AGI]NCY <br />I herby af firnr undcr Jrnaltyof perjury that there is a conslrucli<[ lcrdiDg aScncy for the perfomrce of the work for which this pemil it <br />issucd (Scc. :l{)97, Civ C.). <br />Lendcr's Nanrc: <br />Irndcr's At[!rcss: <br />APPLICANT t'E(:I,ARATIoN <br />I hercby aflimr undcr pennlty of perjury one of the followirrB declarations: <br />Dcnolition Permils-Asbcstos Norification Federal ReSulalions (Title.l0, Piln6) <br />-Required <br />kiler of Ndification <br />-l <br />cenify that thc fedcral rcgulatioN rcgading asbcstos rcnnvil arc not applicable to this prciei. <br />_l cenify th.l I have rcarl this applicalion and slnrc thnl thc above in[ormalion is core.l. I ngr@ to comply wirh all City and County <br />onlinances and State l-aws rclating lo building constructidL ard hereby authorize represcotalives ofthis City and Coutrty to enter utnn the <br />at()ve rcnli()ncd prol--ny lbr inspcction puqx)scs. <br />Appli(nnt or Agcnt <br />I'rrmilee natrrr (odnl): <br />l)xtc:_ <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVl nsu lation <br />Roof Sheathing 5 lslto ffiN)m 917 <br />Shear Wall u <br />I <br />Framinq <br />lnsulation/Enerqy <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 />Enqineer Final Report <br />Flood Zone Certif <br />FINAL 6-z H A2)/Lc ,s t t24cs\ / Zry) <br />Certificate of Occupancy <br />Notes, Remarks, Etc.