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BUILD!NG- !NSPECTOR RECORD Bev. 0B-07-201 5 SITE.WORK DATE ID/SIG.COMMENTS oWNllR Iltlll,l)llR l)lll,CARA'IIoN I hereby affirnr under penahy of perjury rhal I anr exempl fronr rhe Conlncloc l.iceose Lrw for thc followirg rcason (Scc.703 1 .5 llusincss nrd Prol'cssion Code): Any City or Counlv which rcquircs a l^-rrnil h constnlcl, allcr. irnprovc. dermlish or rcpair any stilc[rre. prior rr) its issuance. also requires the applicant 1()r such p€rnri( rr file a siSned statemetrt that lE or she is licensed pursuant to th(' prevision\ of lhc Contraclor's l-icenscd liw (Chaptcr 9, ComrncncinS with Scclion ?UX) of l)ivirion 3 o[ lhc Business and ProftssionsCodc)orthathcorshciscxemplthercfion)oDdlhcbasistirrtlrcallegedexenrpti(nr. Anyviohti6ofSectionT03l.5hyany rpplicailt for r pcnnir \ubjects lhe npplicanl to n civil pdnilty of nol more thatr fivc hundred dollnrs ($5(x)). _I. as owner ol tlE prolrny. or rny cmployces with wages as thci solc cornpensation, will do thc wtrk and thc stMturc is mt irleulerl or offercrl for sle (54.7044. Busirtcss and Prrfesskrns C(xle: The Cunnclor's Licensc Inw d@s nol apply to an owncr of lhe popeny who build$ or inrprovcs therc[ a[d who d(Es such work himsell or hcrself o( through his or her owu enrployees, providcd rhal such improvcrEnls arc mr inlcnded or ollcred for salc. Il. howcvcr, rhc building r)r improvcmnl is sH wirhin one )rff ofconrlrleri(xr, rlrc Owner Builder will have thc burden of prcvirg thdt lt or she did not build or impmve the pnpcny for the purlFse of sb). _1. as owner ofthe prop€fly, am exclusively contracting with lic.n*d conlroctoft to conrlrucl the pNject (Scc. ?04.{. Business and ftotlssknCode:'lheCoiltrrctor'cI-icetrseLawdoesnotapplytoanowneroIpropertywhobuildsoriDprovesthcreon. nnd who conlracts lor such pr(ticcts with a Conlracto(s) licen$d plr\uail (r lhc Contracloas Liccnse [iw). -IanlexemItundcrsection-.B,&P-C,lbrlhisreasoil. W0RKI]RS' C()MPI:NSATION DT]CLAR{TION I hcrchy atlirm undcr pcnnlty ofpcrjury onc ofthc tbllowing dcclararions: )y'llfirtsuemlwlllnuinlairaCenili(atcofConsenttosel[hrsurcforworkers'compemation,as pruvirlerlforbyScuion]700ofthc's(utf,r Coac. tor rhc l^-rformncc ol lhc work lbr which thc pcrmit is i{surd. _[haveandwillnraintsinworkcrs'compensationinsurancc,as rcquiredbySeclfun3T0OofthebborCode,forthepcrfomrceof thc work li,r whrch this FErmil is issuql. My workers'cunicr ml nunrhcr iue: Policy 5 o I -o( -7910 _l ccnity rhrt in thc lNrlormrnce of lhc work ,r,r which this pcrmil is issuc(!, I shilll not cnrpby rny pcrson in any nranncr so as lo bccorrc suhjccl to thc workcrs'compcnsation laws ofCilil-ornia. aDd agrcc thdt il l slnuld bccoila suhjcct lo lhc workers' conlpen\atioD provi\ions ofSection 1700 ofthe Latbr Coile, I shall, fof,hwith con)ply with tlDs provisions. WARNING: Failurc k, scurc sorkcrs'compcnsation covcrage is unlawful. and shall subjcct an cnrploycr h ainrinul Jtftthies and civil llnes up rc one hundred thousilnd dollnrs (Sl(X),(XX)), in rdditior to lhe cosr ol'coilrpensalion, damrgcs ts trovided for the Section 1076 ofthe trlnr Codc, inerest and allorrcy s fees.Y)o LICENSED CONTRACT0R DECI-ARATION liccnscd undcr prcvision ol Chaptcr 9 (commcncing with Section 70tn) ol Division 3 liccnsc is in full li)rcc ud ellcct. I hcrcby al'lirm undcr pcnalty ofpcrjury lhat I arn of thc Business and Prcfcssions Crxlc, and my I l-iccnsc L Numltr:55L CONSTRT'CTION I,I.]NI)TNG AGI]NCY I herhy aflirm under Jrnallyof periury that there is a con{tilcrioil bndiug agemy lirr the prfr)rmrce of the work fbr which ihis Fmrir is issucd (Sec. 1097, Civ. C.). l-cndcr'\ Nnnrc: hndcr's A(l(lressi APPI,ICANT DECLARATI0N I heEbv affmr under penalty of pcr.iury one of the following dcclilrtions: Denrolition Permils-Arbeslos Ndification Federal Re8ulations (Title.l0, Pan6) _Required Lctter of Notificalion @ r"tifV Wt the fedcral regulations regarding asbcstos rcnroval arc not applicahl. rc this Frojeu. I f,ffcenrfy rhat I hxve rcild rhi\ applicnt {irJirnrrces and Starc Laws rehtrrg tr hur ion iuxl stnte thal the ahove infornution i\ core.l. I aSre to comply wilh all City and County ,reprcsenlrlives oflhis Ciry and Couilly lo cnter ulDn tlEaulhorize atx^'c nrnli(,ncd prolEny lbr Applicant or AEcnl l'(nliler nanre G, o94L(Zo Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenVl nsu lation Roof Sheathinq Shear Wall 7,4 /zd kul Framinq t/ lnsulation/Enerqy Drywall Ext./lnt. Lath Brown Coat lMasonry Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif FINAL Vrr/zaeo ZcrE lv e ,Z-o9 2rl Certificate of Occupancy / Notes, Remarks, Etc. ,^", 03 '0140