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BUILDING. INSPECTOR RECORD <br />Rev.0B-07-2015 <br />SITE.WORK DATE ID/SIG.COMMENTS OWNIIR ltl.llLl)1ll{ l)I,]i.CARA'l'ION <br />Ih€rebyaffimrunderpcnaltyofpeaurythatIanrexenrplfronrtheCbnlra.los l-icenscL:rwforthefollowingreasn(5{.7031.5 <br />llusincss rnd Proltsrion Code): Any Cit], or Countv which rcquircs a f*rmit !r construct, ahcr, improvc, dcrmlish or repair any <br />struc[rre. prior b ils issuance. also requires the applicaDt ti)r such pem)il to file a signed slrtenrent that lE or she is liccnsed pursuanl <br />to thc provisions ol lhc Contracto.'s l-iccnscd law (Chapler 9, Commencing wilh Scction 7(XX) ol l)ivision J ol thc Business and <br />ProfcssiolsCode)orrhstheorsheisexempltheretromandllEb4sisti'rtlEalle8edexenrpliql. AnyviolarionofSecttrnT03l.5byany <br />npplicailrfornpernitsubjectsrhc dpplicantloacivilpcnilllyoInotrnorethufivehundreddollnrs($5(X)). <br />_1. &\ owner ol lhc pro[r(y, or my cmployccs with wsgcs as lhcir solc compcnsation, will do thc work and lhc struclurc is mt <br />iileBled orofTeredforule(Se.701-l.Busincsl0ndPmfcssionsCcrlc:TheContrlctor'sLicen*Lowd@snolapplyloanownerof <br />theprulEny wk)buildsorimprowslheNn.ilndwhod(EssuchsorlihimselforlErsclforlhrou8hhisorherowDempkryecs, <br />providcdrhalsuch irnprovcrrcntsecnorinrcndcdorolfcrcdlorsale.ll,however,lhchuildingorimprovemntissoldwilhinoneled <br />ofconplcli(nl the Owilcr Builder will have thc burden ofpnrving tluu lrc or she clid not build or impnrve the propcny for llrc pur1x)rc of <br />slc). <br />_1. as owner ofthe propeny, !m exclusively contraclin8 with licensed conlrachrs to conslrucl lhc prcject (Sec. 704,1, Busiless <br />alxl f\rlissi(trrCode:ThcCoiltrack),'sLicenscLawdoesnotapplyk)anowDeroll)ropenywhohuildsorimprovesthereon. <br />and who contracls lbr such proicls with a Contoclo(s) licenscd pursuxnt rc lh! Coilraclor's l,icense Law). <br />-Ian)excmplunderSection-'B.&P,C.ti)Ithisreason, <br />woRKt:Rs' cot\t PUNsA'iloN <br />I)I]CI.ARATIoN <br />I hcr('hy 0llirm undcr pcnalty of pcriury onc r)l lhc lbllowinB (lcclarali('ns: <br />_I havc anl will nEintain a CcnitLate of Co[sent to SclLlnsure for wrrkers' conrFnsation, as prcvidcd for hySection J700 of thc <br />htFr Cdle, for lhc lErformmc ol lhe work for which rhL pcrmir ir isrlcd. <br />_thavcunrlwill nuintainworkeas'compcnsalioninsurance,as requiredbySecliolST00ofthctiborCode,forthef€rfomreeof <br />the work lbr which this 0crmil i9 issucd. My workers' comfE[sation insurmcc crrid and lnlicy numbcr ile: <br />Policy Nuntber: lixpires: <br />_l c('nify that in thc pcrfilrnrancc of lhe work for which this pcrmit is issued. I shall nol cnploy any person in any manner <br />so as lo hccorrc suhjcct to the workcrs'conlpensAtion laws ol Californir. aDd agrcc lhnt ifl should bccorrc suh.icct 1o thc <br />workers'conlpensrrionprovi!ionsofSection3?00ofthcLborCode,lshall,fonhwithcomplywiththo$provisions. <br />WARNING: Failurc rc scurc workcrs'conllEnsation covcrugc ir unlawful. anrl shall subjcct an cmployer ro oiminal lrcmhies and <br />civil lines up to one hundred thousand dollnrs (SI(X).(XXD. in additiorl lo the cost ofconrpcnsation. daergcs as providcd for lhc <br />Seclion J076 ofthe LatDr Code. inlcrest and ntk)ruy's fee\. <br />LI(--ENSED CoNTRACTOR <br />T)ECLARATION <br />I hcrcby al lirm undcr F-nalty of pcrjury rhat I am licensd undcr provisir)n olChanrcr 9 (cornmncing with Scclion 70(x)) ol Division 3 <br />of thc [Jusincss and P()fcssioro Codc. frl nrv licensc is in tull lbrcc el clfect. <br />Licensc Clnss:-l-iccnsc Numkr: <br />CONSTRIJCTION T,I:NI)ING AGI:NCY <br />I heRby aflirnl undcr Ftnaltyofperjury thrl there is a con\truction lcndi0g agerrcy litr the perfrtrrurNe ofthe work for which this Fmrit is <br />issucd (Scc. 1097. Civ. C.). <br />l-cr(lcr's Nrntc: <br />hndcr's Atldressr <br />APPI,ICANT DECI,ARATI()N <br />I hereby rflimr untlcr pnnlty of perjury one of the followin8 declarntioDs: <br />Denrelirion Permits-r\sbestos Notification Federal ReSulrtions (Title.l0, Pn(6) <br />_Reqrired Letter of Notificatiu) <br />_l ccnity that thc fcdcral aegulatioDs rcgarding astEslos rcnDval arc not applicablc to this pmjcrct. <br />_l certify thal I lhvc rcad this application and state that lhc dbove infornulion is corcct. I agre lo comply with all Cily and County <br />ordirances and Starc bws rehtilS lo buitding corlslruction, iual hereby au(horize reprcsentalives of this City and County lo cntcr ulDn tlE <br />lt(rvc mntiored propc(y for iNpcction puqnss. <br />Applicxnl or Agcnt <br />PrnnltE Mmc (prlnl): <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVl nsulation <br />Roof Sheathinq €ltslu bllwtu-*ry <br />Shear Wall t, <br />Framinq <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />JVlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />I i <br />F!NAL D?O <br />Certificate of Occ <br />Notes, Remarks, Etc <br />Ilet.:- Atnliont:l,'^4 z:MWil)