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BUILDING. INSPECTOR RECORD <br />Flev. 0B-07-201 5 <br />SITE.WORK DATE ID/SIG COMMENTS owNuR lrull,t)t:R t)ul.cARA'IloN <br />IherebyaffirmundcrpenaltyofpcriurythatIamexenrptfronrtheCuxractos License[awforthefollowingreasn(S(.?0J1.5 <br />llusiness and Prolcssion Code): Any Cily or County which rcqutcs 6 lrcrmit l(t construcl, allcr. irnprove, dcrnolish or repair any <br />slructurc, prior b its issuancc. aLso rcquircs the applicailt ti,r such pemit o file a si8ned $tatercnl that lE or shc is licefuEd pursuanl <br />to lhc provisions ol-thc Conrracor's l.iccnscd l,aw (Chaptcr 9, Commcncing wilh Section 70([) ol Division 3 ol the Business and <br />ProlessionsCode)orthatltorshcisexempltherclionrandllEbasisfbrtlEallegedexenrptiur. Anyviolati(mofSeclionT03l.5byrny <br />npplicant lbr a pefinit subjects lhe rpplicant to i civil penilty of not morc thiln fivc hundrcd dollars ($5U)). <br />_1. as owncr o, thc prolEfly, or rny emplovees with wagcs as thcir mlc cornpcnsation, will do lhc work and thc stfflurc i$ mt <br />iilcRled or offered for sale (Se.7Ol4. Business and Prcfessions Codc: The Conlrrck)r's License Law does nol apply lo an owner of <br />thepmpcdy wlnhuildsorimprovesthereil.andwl$dNssuchworkhimselforhcrsclforlhrouShhisorlErownemployees, <br />proridcdrhalsuch improvcrrcnls@mtintcndedorolTcrcdlbrMlc. lt.hoccvcithcbuildiagorimprovemnlissUwilhinoncyee <br />of conqrletirm. the Owner Builder will hdve thc burdcn of proviD8 lhat lE or she did Dot build or ifipmve the pmpdy for lhc puqnse of <br />srlc). <br />_1, as owncr of thc propcfly, am cxclusivaly conlracting wilh licenrcd conlraclors 10 c_onslruct the pmject (Scc. 7(N4. Business <br />aill PDlissbnCodeiTheContractrr'sLicenseL6wd@snotapplytoanownerofprofrnywhobuildsorimprovesthercon. <br />and who coilmcts for such projects with a Contractor(s) liccnscd pursuul to lhe Cootractor's Licensc Law). <br />_l anr excmpt utrder Sectirln-. B & P ('. l'rrr this reasrrt. <br />lhler- <br />\YORKtIILS' CONIPENSATI()N <br />DECLARAToN <br />I h!'rcby atllrm undcr pcnahy ofpcrjury onc ofthe Ii)llowing declarati()ns: <br />_lhaveurlwill maintainaCerlificateofconsenttoSclflNureforworkers'conrpensation,as pruvidedforbyS.ction3T00ofth. <br />tntx)r Codc, for lhe perforrorce of thc work lbr which lhc pfrmil is i\sucd. <br />_l have and will maintain workars' conrpcnsalion insurance, as required hy Seclion 3700 of thc Ilhor Cbde, for thc perfommc of <br />rhc work lirr which this pcrmit is isswd. My workcts' compcnsation ifl\urancc caricr i{xl f)licy numbcr mel <br />Policy Nuiltber: l'lxpircs: <br />_l ccnity that in thc pcrlornrancc of thc work for which this pcrmil is issucd, I shall not cnrploy uny person in any nrmner <br />so as to bccom suhjcct lo lhc workcrs' compcnsation laws ofcalilorilia. atrd agrec thd if I should bccorre suhjccl to the <br />worliers'compen\ationpruvisionsofSectionlT0OofthcLahorCodc,lshall,fonhwilhconlplywithlhosprcvisions. <br />WARNING: Failurc to $cure workcn'compensattrn covcrdgc is unlawful, and shall subject an cmploycr to friminal Fnahies und <br />civil lines up b onc hundred thousand dollars (S100,(Xn), in addition lo lhe cosl ofconrpens{tion, damrgcs !s providcd for lhc <br />Scction 3076 ofthe tabor Code, iNerest and attomy s fce\. <br />I)nlc:_ <br />LIC'ENSED CONTRA (--TOR <br />DECLARATION <br />I hcreby allirm undcr pcnaky ofpcrjury lh.t I .m licensd undcr provi$ion ol'Chaplcr 9 (cornmncin8 wilh Scction 7fin) ofDivision l <br />of rhe Business and Profcssions Code. and mv liccnsc is in full forcc md elfcct. <br />[-iccnsc Cliss:-l,iccnsc Nurnher: <br />Dstc <br />- <br />Contraclor: <br />CONSTRIIC'TION I,I.]NI)ING A(;1)NCY <br />I herchy allirnl under [rcnahy of pcriury lhnt there is a con\rnrctbn lcrxlilg r8ency li)r the Nrfomunce of the work ti)r {hich this pemlit is <br />issucd (Scc. l()97, Civ. C.). <br />l-cnder's Nililre: <br />lxnder's Address: <br />APPLICANT DECLARATION <br />I My aflimundcr pcnalty of pcrjury onc of thc following dclaations: <br />Dcmlilion Permits-Asbestos Notification Fcdcral Rcgulalions (Titlc 40, Pan6) <br />_R.quircd [rttcr of Notifi calion <br />_l cdili thit rlrc fedcral regulatioro rcgarding ashcslos rcmval aE nol applicablc to lhir prcirt. <br />_l cdify that I havc rad this application arxl stalc that lhc abovc infomlion is corcct. I a8r€ to comply with all Cily aftl County <br />orlinanccs and Statc kws relating lo hoiHing constructio[ arxl hereby authori4 r.prcsntativcs oflhL City 8nd County lo cnlcr upon thc <br />above ftnlt)ned proprny lbr inspedion puqnses. <br />ADDlicent or Apmt Sisnatuft: I)alc: <br />Prmlle nEme (Drlnl): <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVl nsulation <br />Roof Sheathino <br />Shear Wall i.td 7 a9iat U/vf)Dtnnzz-# 8< <br />Framinq t, <br />lnsulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />lt/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />tt <br />FINAL lSlr l?a ,Dtm c n-fi dq <br />Certificate of Occupancy I vv <br />Notes;Remarks, Etc. <br />t't'