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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS oWNER BUILDER DELCARATION <br />Iht'rcbyall'rrmundcrpcnaltyofperjurythatIamexcmpttiomthcContraclors l-iccnscLawforthcfrrllowingrc0sn(Scc.70.ll.5 <br />Busincss tnd Pnrfbssi<lr C<xlc): Any City or County which rcquircs a lErmit lo construcl. allcr. improvc. dcmolish or rcpair any <br />stntcturc,pri()rtoits issuancc,alsorcquiresthcapplicanllorsuchfrcrmilt)lilcasiSncdstatenEnt lhathcorshcisliccnscd fursuant <br />k) thc provisions of thc Contractor's Liccnsed kw (Chantcr 9. Commcneing wilh Scclion 7fi)0 of Divisi()n .l of thc Busincss and <br />Ptl)lbssions Codc) or thtt hc or shc is cxcmpt lhcrcliom and thc hasis li)r thc allegcd cxcmption. Any violation of Scction ?0.1 I .5 by any <br />applicanlli)rapcrmitsilhjectsthc applicanlloacivilPcnaltyofnolmorethanlivehundrcddollars($5U)). <br />_1, as owilcr of t hc proFrty. or my cnlpk)yccs with wngcs as lhcir solc conlltnsalir)n. will do lhc work an(l the strucluc is n(il <br />ililcndcd or ()llcrcd lilr salc (Scc.T044, Business nnd Proltssrrns Crxlc: l'hc Conlrack)r's Liccnsc l;lw docs not apply kl an owncr of <br />thc pr)Fny wkl huilds or inrpnrvcs thcB)n. anl wlx) dcs snch work himsclfor hcrsclfor through his or hcr own cnrployccs. <br />providcd that such inrpll)vclrcnls trc trot ililcndcd oroftcrc(l li)r salc. It. howcvcr, thc huilding or irnprovcmnl is sol.l wilhin riltc yctr <br />(,1 complclRrr, the Owncr Buiklcr will htvc thc burdcn ofprovurS that hc or shc did not build or improvc thc pn)lEdy li]r lhe puryx)se of <br />srlc). <br />_1. as owncr o[ thc propcrly, aD cxclusivcly c()ntractirUl wilh liccnscd conlrack)rs i) construct Ihc frcjcct (Sec. 7044. Busincss <br />and PrutLis\iil Codct 'l hc Contrack)r's l-iccnsc Law docs nol apfly k) an owncr ofpropcrly who huilds or improvcs lhcrcon, <br />and who contracts t()r such pojeets with a Glntracbr(s) licenscd pursuanl k) lhc Conlrack)r's Liccnse [.aw). <br />I am cxcnrDt unrlcr Scctiur-, B. & P.C. lirr this rcason <br />TVORKI]RS' CONIPENSATION <br />DECI.ARATION <br />I hcrchy al l ir nl undcr pcnally ol pcrjury one oI lhc lollowtrr8 dechrrti{rls: <br />_l have url will maintair a Ccniticatc of Conscnt b Scll:lnsurc lbr workcn compcnsation, as providcd tbr by Scction 3700 of thc <br />t,atx)r Colc. lbr thc pcrlbrmancc of lhc work for which thc pcmit is issued. <br />Ar;anrl will nrairrlain workcrs corrpcnsatiul Scclion -l7U) of thc hbor Codc. ti)r thc pcrli)rmancc of <br />li)r which tht( pcrmil is issucrl. My ca[icr imd F)licy numhcr dc: <br />,/q/)AI'olicy /t, <br />-l <br />ccnily that in lhc frcrlbrmancc of lhc work li)r which this pcrnrit is issucd. I shsll n(i cmpkry any ;rcrson in <br />so as b hceomc subjccl b thc workcrs'cr)nrpensrtir)n laws olCalili)rnia. and agrcc lhal il I should hcconE subjcct k) thc <br />workcrs' compensrti()n provisirills of Scction -1700 of thc l.atx)r Corlc. I shall, Ii)rthwilh comfly wilh lhosc provisi(nls. <br />IVARNIN(I: Fiilurc k) sccurc w()rkers'eonrpcnsrlion covcragc i\ unhwlul. anJ shall subjccl an cmphycr k) dimintl lrcmltics and <br />civil lines up to onc hundrcd thousanJ rlollars ($100.U)0),' <br />Scctiur .1076 of thc l,ntDr Codc, inercsl Md alk)rrcy s l-ccs. <br />i(ldition kr lhc cosl ()l'compcilsalion, (lanrages is providcd fi)r thc <br />I <br />l)1..( 1..\l{,\ Il()\ <br />I hcrcby rllirm und('r lrcnally ol pcrjury lhat I anr lccntd undcr pntvision 9 (commcn!ing with Sculion 7(XX)) ol t)ivision ] <br />ol lhc Busincss rn(l I'roltsstrns Codc. ild nly liccnsc is tr) lull l'()rcc dhd clli'el <br />/? <br />al.i(('nsc <br />t <br />I hcrcby alfirrn undcr Frcnalty of Frjury that llrcrc is a consltuction lcnding atlcncy for thc pcrfomancc of thc work l(rr which lhis lErmit is <br />issucd (Scc. 1097, Civ. C.). <br />hndcr's Namc: <br />kndcr's A,ldrcss: <br />APPLICANT DECLARATION <br />I hcrchy allimr undcr lrcnalty ol pcrjury onc ol lhc li)llowin8 dccl$ali{ils: <br />Dcilxllition Pcrmits-Ashcskrs Nolilical(m Fedcrdl Rcgulali(ns (Titlc 40. Part6) <br />_Rcquircd Lcllcr ol Notilicrlion <br />_l ccilili lhal thc lcdcral rcSulations rcgudinS asbcslos rcmovilltrc nol lpllicahlc k, this p(ice t. <br />with all Cily and Cr)unty <br />rnd CounlY n) cnlcr uFx)o thc <br />Applicant or Agent <br />Pcnnilee ntrnc 4 <br />l)alc: i t- tT-)o <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVl nsu lation <br />Roof Sheathinq <br />Shear Wall <br />Framinq (o h/^^trt/J 1-2J-/}'.tt;flr D <br />lnsulation/Energy (./ <br />D-rywall /A <br />€xt)tnt. Latr 7-L)-n w+t0 \ <br />Brown Coat U /\I <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />FINAL 6/t/t co ) <br />Certitic'ate of Occupancy I t <br />Notes, Remarks, Etc. <br />)