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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS Owner-Builder Dccltu6rion <br />IherebyaffrrnrunderpenaltyofperjurythatIamexemptformtheConlractors LicenseLawforthefollowingreason(sec703L5Busincss <br />.nd Profcssion Codc): Any ('ily or Counl), which requires a perrnil lo conslrucl. aher. improve, dcmolish or rclair any slruclure. prior ro its <br />issuance,alsorequircthcapplicantforsuchpcrmiltofileasigncdslalcmenl thf,theorsheislicenscd pursuantlotheprovisionsofthc <br />Contraclor's Licensed Law (Chapler I, Conlnrencing wilh Seclion 7000 of Division I of the Business ind Profo.ons Code) or lhat he or <br />shc is cxcmpl thdefrom and lhe basis for the allcged cxemplion .Any violation ofSection 70-1L5 by any applicant f&l a pennit subjects rhe <br />applicanl 1o a civil pcnalty ofnol rnorc lhan llve hundred dollam ($500). <br />l. as owner oIlhc properly. or my employces with wages as lheir solc cornpensation. will do the work snd the structure is nol inlended <br />or offered for sale ( Sec 7044. Busrness and Professlons Code The ContrBctor's l-icense Law does nol applv to an owner oflhe propeny <br />who builds or irnproves lhercon. and who docs such work himsclfor herselfor through his or her owf, employees. provided lhat such <br />intprovcmenls are nol inl.nded or offercd for salc. If. howe!cr. thc building or irnprovemenl is sold wilhin one ycar ofconlplction. lhe <br />()wner-Builder rvill have lhc burdcn of proving lhat he or she nol build or improve l(]r the purposc ofsale)- <br />-. l. as owner oflhc property. am cxclusively contracting with licensed contractors k) construct thc prdecl ( Sec. 7044. Business and <br />I'rcfessi()n Code The Contractor's [-icense hw does not apply to an owner of propeny who builds or inrproves lhereon . and who <br />contrlcts for such with a Contr.clor(s) licenscd pursuanl to the Conlrador's Licensc [rw.) <br />_l am cxcmpt undcr Sslion _.8. & P.C. for this rccon. <br />Datc: Owns: <br />WORKf, RS COMPf, NSATION I'ECLARATION <br />I herehy aflirn under penalty ofpcrjury one oflhe following declaratioils: <br />I have and will maintain a Cenilicatc ofConsent lo Self-lnsure for workers' compensatron, as provided for by Secrion 37oo ofthe <br />lrbor (bde. for lhc pcrforrnancc oflhc work for which thc pennit is issued. <br />I have and wrll marnlain workers @mpenslion insurance. as required <br />work for whrch thrs permI rs rssued My workers conrpensalron rnsurancc <br />canier S",{-tfDot\4,21^rs <br />by Section 1700 ofthe labor Code, for the perforroncc ofthc <br />canicr and policy numbr arc:,,_L41 ._ <br />rori.yH,,u",,[dl?lrtf - /t( - -Expircs:(This scction nced not be c6rnplcled iflhe pcrrnit is fiir One hundred dollars {$100} or lcss) <br />I ceni[y lhnt in thc performancc oflhe work for rvhich lhis is I shall not any person in any rnanner so as to <br />to lhe workers' compenstron laws ofca rfl subject to the workers <br />conrpensalion <br />trare, .h <br />provisions of Sectionlrlr[1700 oflhc l-ahor ('odc. I provisions.. <br />wARNINC ,railure to secure workers compensalion coverage rs unlawful. and shall sub_lect an employer to cdminal pensllies and civil <br />fines up to onc hundred thousand dollars ($100.000).in addilion to lhe cost ofcompensalion. darnaScs &s providcd for lhe Scclion .1076 of <br />the Labor Code. rnler6t and allorney's fees <br />LICENSED CONTRACTORS DECLARATION <br />I hereby amnn under penalty of pcrjury that I am licensed under provision of ('h6pter 9 (cornrnencing with Section 7000) of I)ivision -3 of <br />lhe Business and Profcssions Codc. and my license is in full force and effect- <br />Licensc Class: <br />l)^tc: _.__-_ <br />ourllrq [,icense I w*( onlraclorl <br />CONSTRT'CTION LENDING AGENCY <br />I hcrcby aflirm undcr pcnally ofpcrjury that thcrc is a coNtruction lending agcncy for thc pcrfomance ofthe work for which this permit is <br />issucd (Ss. 3097. Civ. C.). <br />Lender's Name <br />l.cnder's Addrcss: <br />APPLICAN'I"S DECLARA"TION <br />Demolition Permits-AstEslos Notification Federal Resulations ('l itle 40. Pan 6) <br />_ Required t-eller of Notification <br />I cenify thal the federal regulalions regardinU asbestos reilroval are nol applicablc to this project. <br />I ceniry that I have rcad lhis ion and slatc thal lhe ahove information is conect. I agree lo comply wilh all Cily and County <br />ordinances and State [nws authorizc represenl8livcs of this <br />G-o.r., <br />sbove ,nentioned property for <br />Applicant or agcnt sig.: <br />Pcmitlr namc (prinl): <br />Io conslruction.u,id: <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subfloor/VenUlnsul <br />Roof Sheathing <br />Shear Wall <br />Framing <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />,fl <br />FINAL ld/nz/E -lM/r ,) <br />Certificate of Occupancy '/<w <br />Notes, Remarks, Etc