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BUILDING- INSPECTOR RECORD <br />Rev.0B-07-2015 <br />SITE.WORK DATE ID/SIG COMMENTS owNuR Bt rILI)ER t)t]t.cARAT()N <br />I hereby affirnr under penalty of perjury that I m) etcmpt from the Contraclo6' l,icense [;rw for the following reafn (Sc.7031-5 <br />llusincss and l,rolcssion Codc): Any City or Countv which rcquircs a pcrmil o consnuct, altcr, irnprovc, dcmolish or rnair any <br />stnrcture.priort()its issuancc.alsorequireslheapplicatrtfirrsuchpernit()fileasignedslnlcmnt lhatlEorshaislice[Ed pursuanl <br />lo lhc nrovisions of lhc Contractor's l,iccnscd l-aw (Chaptcr 9, Cornrnencing wilh Scction 7(XX) ol l)ivirion 3 ol lhc Business and <br />Pr()ftssi()osCode)orthatlEorrhcisc\cnrpllhcreftonlandllEbasislirrtltrlle8edexenrptiul. Ailyvi()latiurofScctiorT03l.5byany <br />applicrnrforapcnnitsubjecrsthc {pplicanrtoncivilpennltyofnotrnorethrnfivehundreddollars($5U)). <br />_1. as owncr ol'thc propfly. or my cmplovecs with wages as lheir slc compcnsalion, willdo lhe work ard thc slMture is m( <br />irilendcd orofferadforNule(5*.7044.BusincssandPmfessionsCodc:TheCuilruclor'sLiccnscLawrloesnolapplybflnowncrof <br />th€pfi)pcdy wh)buildsorimprovestlHsilafilwhodocssuchworkhinrselforlErsclforthmu8hhisorherownemployees, <br />prol idcd lhat such impmvcrrcnts e mt intefilcd or ollered for sle. ll, howcvcr. the blilding or itrprovcrrent is soH wilhin onc }til <br />ofconuleliol, the Owncr Buildcr will hsve the burden ofprcving lhd hc or shc dirl not build or improve thc prc[Eny for llE purfnse of <br />$le). <br />_1, as owner of thc pmpcrly, am cxclusively contractinS wilh liccnFi conlraclon to conslruct lh. pmject (S4. 7014. Businc\s <br />arrl PnrtksbnCode:TheConlraclor'iLicenscLawd(EsnolapplyloanownerofproJrnywhobuildsorimproveslher6n. <br />and who conlracts for such prcjecli with a Coilraclor(s) liccnsed pursuill lo thc Conlractor's Liccnse Law). <br />_l anlexempl under Section_, B. & P.C. lbr this reason- <br />n---- <br />EA8IE&ISOIIIENSAIIQN <br />DECLARATION <br />I hcrchy aftirm under f'enahy ofpc.jury one ofthe following dcclMarions: <br />_l havc and will Mintain a Ccnilicatc of Conscnt to Sclf-lnsurc for workers' contpcnsalion, as pmvided for by Scction J700 of tha <br />Lahor Codc, for the performmc of lhc work for which thc permit is i-ssued. <br />$flave a$ wrll maintain workcrs' compcnsalion insuramc, as rcquircd by Scclion l70O of thc tibor Codc, for thc IErfomrce of! thc work frrr whie h rhis plrmit is issued. My workers' compensstion ins$rilcc cmier aftl lmlicy numbcr dc: <br />Polic)z <br />_l ccrity thlt in thc prlbrnunce ofthc work for which this pcrmit is issucrl, I shull not en]pby any pcrson in any manncr <br />so as lo hccorE subject to the workers' compcnsation laws of California. and aSrcc that i[ I slnuld bccorre subject to thc <br />workers' comlrcnsrtion provisions of Section 3700 of the Lah)r Code, I shdll, fonhwith comply with thos prcvisions. <br />WARNING: Irailure lo sccure workcrs'compnsalion covcruEc is unlawfirl. nnd shall subjcct u employcr t) fiinrinal Fmlties and <br />civil fincs up h one hundred thousand dollnrs (Sl(x),(xru). in addition to lhe cost of co$pcnsalion, damrgcs ns provided fo. thc <br />Seclion 1076 ofthe titx)r Cbdc, ineresl and atbrcy's fees. <br />?D <br />I hcreby al'lirm undcr pcnahy of pcrjury lhat I arn licenscd undcr ptovision ol Chapter 9 (cornrrcncing wilh Scction 7iln) oI Division 3 <br />of thc Busincss and Pmfcssiom Codc. ill my licenrc is in full forcc arrl clltct. <br />l-iccnsc Nurnher'/ o (61s/ <br />CONSTRUCTION I,ENDING AGENCY <br />I hceby attirm uilder fEnalty of periury thal there is a constructiur hudirg agcE-y fbr the perfomarce ofthe work for which this lEmit i9 <br />issued (Scc. 3097, Civ. C.). <br />kndcr's Nanre: <br />[lndcr's Addrcss: <br />APPLICANT DECLARATION <br />I hdcby affmundcr pcnalty of pcrjury onc of (hc followinS dslarations: <br />Derolition Permits-Asbcstos Notification Fcdcral RcSulations (Titlc 40, Pa.t6) <br />-Rcquired <br />[.tter of Notification <br />_l cediry thit th€ fcdcral regulations rcgarding asbcslos rcnDval aE nol applicablc to this pmFct. <br />Uwgify ,tnl havc rarJ rhis applicalion all statc thal thc abovc infomalion is corcct. I aSre to @mply with all City an<l Counry <br />6dinailccs rnd Statc liws r€latinS to buildinS coNtructiotr ilxl hcreby outhorizc rcprcsntativcs of this City and County lo eotcr ulDn tha <br />rh()vc nrcolir)nc(l lnl)pcrty k,r insl)ccti()n lurIx)ses. <br />Aptllicant or Agcnt <br />I'( rnrilrr name(nrrnr):D( sE/* G Z1 <br />^," t y'tl/zo <br />---.----r------7-_ <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVl nsu lation tl I <br />Roof Sheathing //t6/%v 4rI <br />Shear Wall tl <br />Framinq <br />lnsulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />[t/asonry <br />Pool Fence <br />T-Bar ( <br />Handicap Req. <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif. <br />I I t, <br />F!NAL '/honoY d6 <br />Certificate of Occupancy I <br />Notes, Remarks, Etc. <br />- <br />,,,**,, c 157hre. a^4/ -T,tts ,4tAt) <br />arrnrn*t*-, f ( - =