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BUILDING. !NSPECTOR RECORD <br />Rev.0B-07-2015 <br />SITE-WORK DATE ID/SIG.COMMENTS OWNI]R R I.'II,I)I]R I)ItI,C,\ ITATIoN <br />IhcrcbyrffirnlundcrpenaltyofpcrjurythatIanlexcnlptfronrthcContraclors l,icenseLawforthefollowingrcason(Sec.7031.5 <br />Busincss Ard Pro,cssion Codc): Any City or County which rcquircs a lErrnit lo consttuct, aller, irnprovc, dcmlish or rcparr any <br />stnlcture,priortoils issuance.alsorequiresthcapplicxtrtforsuchperni(()fileasignedstatcnrnt thatlEorsheisliccffed pursumt <br />to thc pmvisions of lhd Contraclor's l-icensed lnw (Chapter 9. Comrncncing wilh Scclion 7fix) ol l)ivision 3 ol the Busincss and ' <br />ProtesiionsCode)orrharhcorsheiscrcmplthereliomandrhch&\istbrtheallegedexen)ptiur. AnyviolationofSectionT03l.5byany <br />applicrnlforrpennitsubjectsthe npplicxnlloacivilpcnrhyoInotmorcthanllvehundreddollrrs($5(X)). <br />_1. as owncr ol thc prolEny, or my chployecs with wagcs as their slc compcnsalion. willdo thc work ard tlE stMrure is mt <br />irxcBled orofferedforsle(S€.T0l.l.BusinessandPrrfessionsCode:TheCotrlractor'sLicenseLawdoesnolapplylosnownerof <br />the pn,pedy wlE trilds or improves thcr@[ old wl$ does such work hinNeltor lErselfor through his or her own employces, <br />providcd lhat such imprevcrents rc not inlcndcd orollcrcd lbr sab. ll. howcvcr, th! h{ilding or irprovemnt is $H within ore pu <br />ofconrpletin. the Owrrcr Buikler will luve the burdcn of provirg lhd lE or she did ml build or imprcvc thc pmpcdy for llr purf$$ of <br />ulct. <br />_1. as owner of the propefly, am exclusivcly conlhcting with licen*d contractom lo conslrucl lle prcject (Scc. 7(N4. Business <br />lril PmtlssknCode:TheContractor'rLicenseLawdoesnotapplytoanowneroIproFrtywhobuildsorimprovcstheredl. <br />and who contracls lbr such proiecls wilh ! Contraclor(r) liccnscd psrsuant to thc Conlractor's Liccnsc Law). <br />_I anrcxenlpt undcr Scctiotr-, B. & P.C. lbrthis rcason. <br />l)xlc:_ <br />lvoRKuRs' ('ottrPuNsA't'IoN <br />DT]CI,ARATIoN <br />I hcrcby alllrm undcr pcnrltv (,f pcrjurv onc ol lhc loll(rwing dcclarrtions: <br />_l have url will rointain a Cenificate of Conscnt to SelFlnsure for worlers' conrpensation, as pnrvided for by Scction 3700 of the <br />tibor Cnlc. for lhc pcrforffirce of thc work lbr which thc permit is issucd. <br />}l <br />rfic <br />havc und will nrain(ain workeN comp.mrlion insurance. as rcquired by Scction 3700 of the Lihor Code. for the Frcrforrunce of <br />work lor which this tErmit is irsucd. My workcrs' mmpcnsili()n insurnncc caricr affl F)licy numbcr [c: <br />*l',n>,| .P, ) <br />Policy Nurnbcr: Erpires:6-z) <br />_l ccrity that in thc pcrfornuncc ol thc work for which this prnrit is issucrl, I shall not cmploy any pcrson in any manncr <br />so as to becorrc subjcct lo lhe workcrs'conlpcnsation laws ofCalilbnlia, and aSrcc lhat iil should bccorre subjcct to thc <br />worliers'conpensltionprovisionsofSectionST00ofthet-atDrCbde,llhnll,fo(hwithcomplywiththosprovisions. <br />WARNINC: Fuilurc to sccurc workcrs' <br />civil llncs up to onc hundrcd thousand <br />Secti{'n :1076 of rhe ljtx)r C'(xle, inleresl <br />conrpcnsati()n covcrugc is and shall subjcct an employcr t| dminal Fmltics and <br />dolhrs (Sl(X),(XX)). in addition cosl of compensnlion, darmgcs as providcd for lhe <br />and allorney s <br />-/Y'?, <br />DI]CLARATIoN <br />I hcrcby al llrm undcr prnahy of perjury lhat I arn liccnscd undcr provision ol'Chaptcr 9 (cornrrcncing with Scclhn 7()0O) of I)ivision 3 <br />of thc Busincss aod Proltssions Codc, iuxl nry liccnsc is in full lirrcc axl clfcct. <br />License Class:Alicensc NurntErl LG) <br />uarc, 2-tQ-?-: <br />CONSTRIJCTION I,I]NI)ING AGl]NCY <br />I hercby aflirm uildcr Fnalty of perjury that therc is a constnrctiotr leildil8 agcRy fi,r rhc FErfomrce of (he work tbr which this [Emir is <br />issucd (Scc. 3Ur7, Civ. C.). <br />[Jnder's Nanei <br />[rnder's A,ldrcss: <br />APPLICAI.tT DECLARATION <br />I hercby affmr undcr penahy of perjury orc of thc following declararions: <br />Dcnrlilion Permils-Asbestos Notification Federal RcgulatioDs (Title 40, Pan6) <br />-Rcqrired <br />ktter of Notification <br />_l cen ili lhat the t''ederal r€Eulilliurs regitrdinS asbesi()s rcnxrval are not atlplicablc b this protcct. <br />above infonration is conecl. I agre to conrply with all City anLl County <br />representalives ofthis City and County to cilter ufDil tlE <br />akrvc nrcntioncd prrpcny filr inspecti()n <br />Applicont or Agcnt <br />l'crDitce nsnl( <br />Dut", Z -l q- ?J <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVl nsulation <br />Roof Sheathing <br />Shear Wall <br />Framinq <br />lnsulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />ft/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputv Final Report <br />Enqineer Final Report <br />Flood Zone Certif. <br />i /t. <br />FINAL <l /)2,/24 .#rcd) <br />Certificate of Occ <br />fNotes, Remarks, Etc