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BUILDING. INSPECTOR RECORD Bev.08-07-2015 SITE.WORK DATE ID/SIG.COMMENTS owNER lt(JILt)l,tR l)1LCAR '|'ION Ihercbyaffirn)underpenrhyofpcrj!rythatIanrexenlptfromthc(:ontraaloN LicenseIrwforthefollowingreason(Scc.7031.5 Busincss and Prolcssion Code): Any City or County which requires n lEtrnit h construcl, aller. irnprove, dcrmlish or rcpair any stnlclorc. pri(,r lo its issuance. also requires the npplicaDl fi)r sucll pcrnril to filc x signed slatcment lhat he or shc is licensed pursuant to lh$ provisioN ol t}k' Contractor's l,iccnscd lrw (Chnplcr 9. Comrncncing wilh Scclion 7(xn of l)ivision J of the Business and Prolts\k)nsCode)orthalhcorshciscrcmplthcrclionlaDdtlEbasislirrtlEallcgedexenrpti(nl. Anyvi()lrtionofSectionT03l.5hyany applicrnl for r pcrmil subjects the npplicant to a civil pcrrnlt!,ofnol nrore than llve hundred dollnrs ($5(X)). _1, as owner ol thc proltnv. or my cmplovccs with wagcs as thcir $lc comFEnsation. will do the work and thc stretue i\ mt interrded orofferedforule(Su.7(X4.BusincssandPrclessiousCule:TheClntrilclor'sLicenschwd@snotapplytoatrowncrof thepropefly whobuildsorimprowstlrcrlr[ildwlbdoersuchworkhinrselforlNrselforthrouBhhisorherownemployees, providcd lhal such imprevcrrcnts te mt hterxlcd or ollcNd lbr sb. Il. however. lhc building or improvcmnt is sold wilhin onc )ru ofcon\)lerbn. the Owrer Buikbr will luve lhe burdcn of provinS lhat lE {)r she did Nt build or inpove thc pmpeny for the puqDs o[ sale). _1, ns owner of lhe propefly, am exclusirely contructinS c,ilh licensed conlrack)n b conllrucl llE pmjcd (Sec. ?(X.{. Business antl [\ulissirr Codcr Thc Coiltrack)r's Licetrs. Law doe\ Dot afply to an owner ofpropcny who btrilds or impr)ves thercon. and who contrlcls lor such proiccls with ! Conlrack]r(s) liccnsed pur\trant to thc Conlractor's Liccnrc Law). -lrnrexemptsndefsccttln-'B,&P,c,titrlhisrc!\otr,Dalq- woRKuRs' coNt PENsA'iloN IX:CI,ARATION I hcrcby nltirm undcr pcnaky of pcrjury onc of the lirlbwing (lcclarati()ns: _lhaveardwill nuintainaCe(ificateofconsentloSelFl[sureforworlers'conrlxnsation,as providedforhySection]700ofthc Inhor Code, for lhe Irdormrce of lhc work lor *hich rhc pcrmir ir i\sucd. _lhrveatrdwilln)aintailworkers'conrpensali(ilinsurance,as requiredhySecli(D3T0OofthetihorCode,forlheprfornunceof thc wo,k lbr which this pcrnrit is issuc(I. My workcrs' comlNnsrrion insurrncc crricr anl F)licy numhcr iuc: Policy Nunrbc.: lixpircs: _l ccnity that in the lrcrlornunce of thc work li)r which this pcrnrit is is$ucd, I shall not cmploy any pcrson in any manncr s as to bccorrc subjcct to lhc workcrs'compensation laws ofcalifonlia. and agrcc lhat ifl slnuld becolrc subjccl to lhe workers' compcnration provisions of S.ction 3700 of thc Llbor Cqle, I slull, fonhwith comply with rho* prcvisions. WARNING: Fililurc to sccure workers'compcnsation covcrugc is unlawful, and shall suhject an empk)yer b miminal Fnalies ud civil fincsuptoonchuildrcdlhousaf,ddollars($100,U)0),itraddiliurtolhccostofconrpcnsalion.daftrges{sprovidcdforlhe Scction 1076 ofrhe Lrh)r Cule. inlerest and atk)rcy's fee\. l)ate:_ I,IL'ENSED C0NTRACT0R DI]CLARATIoN I hDrcby allirm undcr pcnalty of pcrjury that I arn liccn$d undcr prcvisi)n ol Chrptcr 9 (coilrrrcncing with Section 7(Nn) of l)ivision 3 of thc Busincsr and Proflsstrns Codc. md nrv liccnse is in tull firrcc and cllcct. Liccnsc Class:_Liccnsc Numbcr: l)nle _ Conlrsalor: CONSTRI.JCTION I,BNDING AGENCY I heEby atllrm undcr Fnaly of perjury rhrr thcre i! a @nstnrcttnl leldilg agen-y tirr t he perfomrce of the work tbr which rhis trmir Ls issued (Scc. 3097, Civ. C.). Lendcr's Nnmc: knder's Addrcss: APPI,ICANT DECI,AR4.TION I lmby aflm unrlcr penalty of perjury one of thc following rlrelarations: Demolition Pern)ils-Asbestos Notification Federal Regulillions (Title 40, Pan6) -Requted lrttcr of Notification _l certify lhat the federalregulatiors regudirrg asbest)s rennval are not applicahle to this projet. _l cenify lhat I havc rcad this dpplication and slntc th.t lhe above infomulion is corccl. I ngre to crmply wilh all City and County ordinaDces and Slatc Laws rchtiig to huilding coNlruclion, ilnd hereby autk)rize represeDtalives of this City and Couilty to entcr ulDn the atxrvc nrntioncd prrpcny ti)r inspccti()n purposs. Applicsnt or Agcnt Signaturc: Pemillee mme (pdnl): Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Subf loor/VenVl nsu lation Roof Sheathinq Shear Wall Framing lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat lt/asonry Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif. FINAL 2-Zab-Zo[t J t)Lz b(qr) Certificate of Occupancy Notes, Remarks, Etc