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BUILD!NG. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER IiUILI)EI{ t)lll,CARA'I ION <br />I hereby aflrnl under penalty of perjury thal I am exenrpl from lhe Contra.lo^' Licensc kw for rhc followiDg reasoD (Ss.7031.-5 <br />Busincss and Prolcssion Cfirc): Any City or County which requircs a lErrnit lo conslrucl. alter. irnprove. dermlish or rcpair any <br />stnlcture. prior tr) ils issuance. also rcqutes the applicanl li)r such pemil rc fil€ a sigDed slalemnt lhat hc or sha i$ licenrd pursuant <br />to thc provisions of the Conlractor's l,icenscd liw (Chaptcr 9, CornrncncinS wilh Scclion ?(X)0 ol l)ivi$ion J of thc Business and <br />Profcssi()nsCode)orthalhdorrheiserempttherefiomandthebasislortlEallc8edcxenlpti(tr1. AnyviolationofSection?03l.5byany <br />{pplicnnr for a IEnnit rubjects the applicant to i civil penxlty oI not rmre lhan Ilvd hundrcd dollars ($5(x)). <br />_I. as owncr ol'lhc propcny, or my employecs with wagcr as thcir elc compcnsation, will do lhe work and thc slreture is mt <br />iNeftlcd oroffcrcdforslc(Sa-.7(X4.BusinesssndPrcfessionsCode:T|EContrachfsLicen*Lawdoesnotapplytoanowncrof <br />lhepropeny wkrbuildsorinl|)rorslhcre[uldwlpdGssuchwo(khimselforlErselforlhroughhisorhcrownemployees, <br />providcd that such impmvcrrcn(s ile ool intcnded orollcrcd lbr salc. Il, howcvcr, lhc building or improvcrrent is sold within one ycd <br />ofconpleti)[ the Owrcr Buil&r will lurvc lhc bunJcn ofpnrvirrg tlul lrc or she did not build or impreve lh. pmpqty for tlE purln$ of <br />sle). <br />_1, rs owner oflhe propedy. am cxclusively conlractinS wilh licensed conlrack)rs lo conslrucl the preject (Sec. 7(M4. Busincss <br />arxl PnrllsstnCodc:ThcConrractor'sLiceDseLawdcsnorapplytoanowDcrofpropenywhohuildsorinprovestheredr. <br />and who codrnctsforsuchprojcclswithaConrracto(s)liccn*dpursuanlrorhcCoilrador'sLicensct w). <br />_l an) exempt under Sectiur-, B. & P.C. tirr this reasor. <br />WoR Kl:lLS' CoM PI.INSA'I I( )N <br />DI]CI-ARATI()N <br />I hcrcby affirm undcr pcnalry of pcrjury one of lhc ti)llowing dcclararions: <br />_lhaveandwill nuintainuCe(ificateofConsenttoSell.lnsurefi)rworliers'conrpensation,as prcvidedforbyScctionST00ofttre <br />ffiti,r <br />for thc perforrorcc of thc work for which thc pcrmit is irsucd. <br />will nliliilai,l w(,rkers' con)pensali(xl insurance. as required by Seclion 3700 oflhe Labor Ci)de, tbr the perftrrnrance of <br />whiclr is issucd.insurancc cadcr and F)licy numbcr [c: <br />a aPolicy <br />_l ccrlity lhrt i0 rhc pcrlirrnunce of tlrc work fi)r which this l)crnlil is issuc(|. I shilll not cn{)loy ilny pcrson in <br />so as lo hccom suhjccl lo (hc workcrs' conrpctrsal ion laws ol'Calilbrnfu, and aSrcc lhnt if I should becorre to thc <br />worlicrs'.ompensdtionprovisioNofSection3T00ofthebborCodc,lslull,fonhwithcomplywith <br />\{ARNING: Failurc to securc workcrs'compcnsilion covcragc is uohwful, and shall suhjact nn to criminal Fna[ics dd <br />civil fircs up to one hundrcd thousnnd dollArs ($100.{Xx)). iD iddition lo thc cost o[ <br />Secliixr irilerest and atk)fty's fces. <br />I herchy allirm urdcr pcnalty of pcrjury lhat I am liccn*d undcr provision ol'Chaplcr 9 (comrrcncing with Scction 7(fi)) ol l)ivision l <br />()f thc Busincss iln(l Prolissir)ns C(xlc. aod nly liccnsc is in ttll lbrcc and cltcct.6 o <br />[-iccnsc <br />I heEby atfirm under Fnahyofperjury that lhere <br />issued (Scc. 109?. Civ. C.). <br />Lendcr's Name: <br />a conslRrcttD lendir)g agercy li)r the perfomarce of rhc work li)r which this pemit is <br />[Jndcr's Address: <br />APPLICANT DECl,ARATIoN <br />I tEreby affm under penalty of perjury onc of the following rle larationr: <br />Demolition Permits-Asbeslos Notification Fedcral ReSulationr (Title.l0, Pan6) <br />_Reqrired [iler of Ndification <br />pfi)ject. <br />t ug* ro -.pty Jif, ull City anrl County <br />ofrhis Cny and $funryro entd u[Dn tlE <br />Applicant or Agcnt <br />I'rmlilc( nanre <br />^,",' <br />2*)D t'A <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 <br />lnsulation/Energy <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 />, <br />I I <br />FINAL -a//'l/?f, -<44,1-L ) <br />Certificate of <br />Notes, Remarks, Etc.L <br />Rev.0B-07-2015 <br />/ --,