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BUILDING. !NSPECTOR RECORD Rev.08-07-2015 SITE.WORK DATE ID/SIG COMMENTS owNuR Irt Jll,t)l.Ir t)El,cARA't'toN I hereby affirnl under pcnalty of prjury that I anl etenpt from the Contraclos License Law for the followiilg rea\on (Sec.703 1 .5 llusincss and Prolession Codc): Any Cit), or County which rcquircs a Jrcrmit to construcl, nltcr, irnprovc. dcmolish or r(-piir any stnrcnrre. pritr k) its issuance. also rerluires the applicrnt lbr such pernil lo lile ! signed slnremnl ihat lE or shc is licenrcd pursuant to th(, nmvisions of lh* Contractor's I-iccnscd l,aw (Chaptcr 9. Cornrncncing with Seclion 7Un ol Division 3 ol lhc Busincss and ProtessioilsCode)orthatfuorsheisexcmpltherefion)andthebasislbrtlrcclle8edexenlpti(trr. AilyviolatiotrofSectionT03l.5byany ilpplicrnt lbr r pernil subjects the npplic0nt lo i civil perHhy of not Dnre thiln five hundred dolldrs ($5{)0). _1. as owncr o, lhc profLf,y. or my cmployccs wilh wages as thcir solc comJEnsation. will do the work and llE rtNlurc is not ifleilcd orolTeredforsrle(5€.?044,BusirrcssandPrclessionsCtxle:'I'lreContrrctor'sLicenscLiwdesnotapplytoanownerof thc frE)peny wlf,) huild\ o, improws llErdnl dd who docs such work himself or herrelf or tttrough his or her own cmployacs. ['ro\ ide d that such impnrvemnts re mt inlcrdcd or olTercd lor salc. ll, howcvcr. thc building or ifiprovemnt is mld within onc ycu ofconq)leti()n, tlE OwrEr BuildJ will luve the burdcn of pmvinB thd he or shc did frn build or impmve the pmpcny for the puryhs of sale)- _1, ar owner ofthe propciy. am exclusively contracting with licenscd conlmchrs n) conslrucl lhe project (Sec. 7044, Busineqs and Pn)tssiotrCode:TheContractor'sLicenseLawdesnotapplytoanownerofpropenywhohuildsorimproveslhercon. and who contracls for such proiccls wilh x C()ntmcb(s) liccn$d purruaot lo lhc Conlraclor's Licensc [nw). -laneIemptutrderSeclion-'B,&P,C,tbrthisreason, woRKI.tRS' COt\il'8NSA1 tON DI]CI,ARATIoN l hLrchy allirmundcr l)cnrllyol pcriuryonc otlhc lirlklwing (lcchrati('Ds: _l have and will nrainlaiD a Cenilicate of Consenl k) Selt'-lnsure for workers' compensatir)n, as pmvided for hy Scction ]700 of the l-at$r Codc, for thc pcrformncc oflhc work li)r which lhc permit is i\sucd. 4 havc and will nraintain workers' c()mp€nsation insurance, ar required by Scctiotr 3700 of thc hbor Code, tbr the perfornutrce of work tbr My workcrs'iuxl Jnlicy nurnesr uc: /l'olicy _l ccaify thdt in the Jrrfornrancc of thc work for which pcrnil is issucd, I slull not cnrploy rny lrcrson in any mrnncr $ as to hccorrc suhjcct lo I hc workcrs' conrpcnsatioD laws of Calil-onria. and aSrcc thlt if I should bccom suhjcct lo lhc worlers' conrpensntion provisiotrs of Section J700 of the Lak)r Code, I slull, fonhwith conrply with thos prcvisioDs. WARNING: Fnilurc o sccurc workcrs'c\)mpcnsrtion covcrrgc is unlawful. nnd shrll suhjcct nn cmploycr k) criminul lrcnahics civil lincs un to onc hundred thousand dollars ($ion lo lhe cost of damgcs as providcd for Scclir)n ofthe I LI('ENSIit) (t )N'tRA('t'OR t)ti('t,ARA'il()N I hcrcby all'irm under pcnah), of perjury that I arn licensd undcr provision ol'Chapter , (cornmncing wirh Section 7000) of I)ivision 3 of the Business and Professions Code. ml my liccnsc is in tull force iukl cffcct. CONSTRTJCTION I,I.:NI)ING AG]:NCY I heRhy allirnr undcr Fnalty of perjury that lhere is ! con\tructt,n lc[diilg atercy ti)r t he pcrforrorce of the work tbr which this pemrir is issucd (Scc. 3l)97, Civ. C.). I-cndcr's Namc: [*'n,lcr's A,i.lrcs., APPLICANT DECI,ARAT]ON I }r.eby affirm under p€nalty of perjury one of the followi[g declxrations: DenDlition Permits-Asbestos Notificrtion Federal ReBulntions (Title.l0, Pan6) _Rcquired Letter of Ndification _l ccnily thill rhe tldcral regulilli(nls regarding [sbesk)s renx)val ilre not applicable t) lhis projel. and slrlc lh.t the abole inlomution is conect. I n8r@ to conlply wilh all City and County construdion, oxl hereby rulklrize represenlatives ofthis City and Colx[y to cnter uF)n \Prrmilce naD)c lir Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Subf loor/VenVl nsulation Roof Sheathinq Shear Wall Framinq lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat lt/asonry Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Floqd Zone Certif,--.I7/ #z*fzra I dq*il*/* (btltV,Tf, It ,Z-\ FINAL 4/r/fti W Certificate of Occupancy Notes, Remarks, Etc. -U5F/