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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/S!G.COMMENTS OWNI]R BUII,DI]R I)I]I,CA RATION <br />I hereby aflrnr undcr pcnelty of pcrjury that I m cxcmpt frcnr lhc Contractos' Liccnsc law for thc following reaen (SN.7031.5 <br />lrusincss and Proltssion Codc): Any City or Countv which rcquircs 6 permit to construcl, altcr. improvc. dermlish or rcpair any <br />structure. prior to its issuailce. also requiEs the applicant tor such ltmil h file a signed stalcrenl thd hc or shc is licc[td pursuailt <br />lo rhc pmvisions of lhc Contraclor's l-icensed liw (Chaprcr 9, Comrncncing with Scction 7(XX) ot Division 3 of the Busincss and <br />ProtissionsCode)orthithdorshcisexcmpttherefronrlrldrlEb$rstilrllEallcgedexemflioil. Anyviolali()nofScclionT03l.5byany <br />npplicrntforo[Ermitsuhjectsthd {pplicanttoncivilpcnnltyofnotrmrethanfivehundreddollilrs($5(x)). <br />_1. &\ owncr ol thc prolEny. or rny cmployccs wilh wagcs As lhcir solc compcnsrlion, willdo (hc work and lhc slructfc is nol <br />iilended or offered for srle (Se.7(X4, Business and Pn)fessions Code: The CoDtrrc(tr s l,icensc l-nw docs not epply lo an owner of <br />thc prcperty wh{, builds or imDroves therrcu md who does such w()rk hinrsclf or herself or llrou8h his or lEr own employees. <br />providcd thal such improvcrrcnts de nol intended or oll'cR'd li)r srlc. ll. howcvcr, lhc building or irnprovcrrcnt is sld wilhin one ycar <br />ofcompleti(u rlr Owncr Builder will luve the burden of proviDs lhilt lE or shc did Dot build or impn>ve thc Propcny for lhe purlDsc of <br />$le)- <br />_1. as owncr ofthe propa(y, am ciclusively contractinS with liccnrcd contrrclors to con{rual lhe prujcct (Scc. ?044, Businers <br />anl ProtlssbtrCode:ThcContractor'rLicenseLawd@snotapplybanownerofpropeflywhobuildsorimp,oveslhercon. <br />and who conlracts for such projccts with a Contmcb(s) liccnscd pursumt lo lhe G)nlraclor's Liccnsc [rw). <br />_l am exempt under Section-. B. & P.C. lbr lhis reason. <br />WORKtI,RS' ('OMPI.INSA'II()N <br />I)DCI,ARATrcN <br />I hc'rcby allirm undcr p!'nnlty ol pcrjury onc oflhc lbllowinB (l.clxralions: <br />_l have and will nEiNaiD a Cedificate of Corsent to Self:lnsurc for workers' lsmpensation, as prcvided for by Section 3700 of thc <br />Labor C(dc, for thc tErforrorcc of thc work fot which lh! lffmil is i-ssucd. <br />_lhaveandwillnraintainworkcs conpensationinsurance,as requircdbySection3T00ofthclaborCode,forthcperfomBrrccof <br />thc work tbr which this pcrmit is issucd. My workers' compcnsilion insurdncc cmicr ml [Dlicy nunrtrcr de: <br />, -*i-. _ <br />l'olicy <br />_l cc(ili that in thc lrrtbrnuncc of the work for which this lErnrit is issuc(j, I shrll not cnrploy any pcrson in any manner <br />I as to bccorrc subjccl to thc workcrs' conlpensalion laws of Calilonria. and agrec lhal i[ I slmuld bccorm suhjcct lo thc <br />wodiers' comfrnsarion prcvisions of Section 3700 of thc ljbor Cqle, I shall, fonhwith rumply wilh tlN* prcvisions. <br />WARNING: Failurc rr xcun'workcrs'compensation covcrJgc is lnlawful. and shrll suhjcct an cnDloyer to dminal rtmltix Md <br />civil tlnes ul to onc hundred thousand doll3rs ($l(X).(l(Xl), in rddition lo the cost ofcompcnsation, damgcs as providcd for lhc <br />Section J076 oflhe trlxx (lxle, intercst and allofty s fcc\. <br />I,ICENSED CONTRACTOR <br />I)I]CI,ARATION <br />I hcrcby al lirm undcr r*nalty ol pcrjury that I arn licenscd undcr provision o, Chaptcr 9 (cornrrcncinS wirh Scction 7000) ol Division 3 <br />of the Busincss an(l Prrfcssions Codc, md my liccnsc is in full fi)rcc and clfccl. <br />Liccnse Class:-Liccnsc Numbcr: <br />Conlmclor: <br />CONSTRI,]C1'ION I,I,]NI)ING AGENCY <br />I hcreby allirm under Ftralty of perjury lhat fhere is a constnr(ti(tn lendilg agercy ti)r thc perfornurrce of the work for which this pemrit is <br />issucd (Sec. 3097, Civ. C.). <br />lrndcr's NAnrc: <br />lrn,Icr's Ad.lress: <br />APPI,ICANT DECI,ARATION <br />I hercby affmr under [Enxhy of pcrjury one of the followi[g declaratioDs: <br />DenDlition Pernrits-Asbcstos Notificntion Federal Relulations (Title.l0, Pafl6) <br />_Required [itler of Notification <br />_l cefrity thal tlrc lederal reSulatiors regilding astEsk)s rcnx)val are not lpplichble o this projcct. <br />_l cerlify lhal I lilve rcad thi\ {pplical ion and stale th.l lhe atnve iDfornration is corecl. I ngrE lo comply with all Cily and CouDty <br />(,rdiilances and Stale Laws rclat ing to huilding coilslructioil, and herehy authorize rcpresettalives of this City and CouDty lo eiter uF)n the <br />rtxlvc mcntionc(l nropcny lirr inspcction purposes. <br />Applicont or AScnt l)nlc:_ <br />Pemlle mme (prlnl): <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVl nsulation l,r <br />Roof Sheathinq 1/tt looa 7,M <br />Shear Wall v./ <br />Framinq <br />lnsulation/Enerqv <br />Drvwall <br />Ext./lnt. Lath <br />Brown Coat <br />[\4asonry <br />Pool Fence <br />T-Bar <br />Handicap Beq <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />tl tA <br />FINAL 7fL"1/+t fl -4ffit t/ <br />Certificate of Occupancy | -l <br />Notes, Remarks, Etc. <br />Rev.08-07-2015