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BUILDING- INSPECTOR RECORD <br />Rev. 0B-0rr-2015 <br />S!TE.WORK DATE ID/SIG.COMMENTS owNI,tR BtiIl,])t;R I)t],t,cARA iloN <br />IherebyaffirnrunderpcnaltyofperiurythatImlexemptfronrtheContraclos Licenselnwforthefollowingrcr5on,(Sec.7031.5 <br />llusincrs and Prolession Code): Any Cily or County which rcquires a Jrcrrnit lo construct, aller, improve. dcmolish or rcfnir any <br />struclurc. prior k) its issuance. also equircs lhe applicanl tbr such peroril to fik a sigrcd slalercnl lhal he or she is liccred pursuanl <br />to thc provisions of the Contraclor's l,iccnscd law (Chaptcr I, Commcncing with Scction 7fiX) ol l)ivision 3 ol thc Busincss and <br />ProttssiorsCodetorthatlNorsheiscxenrpttherehonlandtlEhlsisl'ortlEallegedexenlptiur. AnyviolatiulofSectionT03l.5byany <br />ilpplicAnt for a pcrmit subjccts thc applicanr to r civil peDaltyofnot rmrc than five hundrcd dolhrs ($5(D). <br />_1. as owncr ol lhc profrny. or my cmplovccs wilh wages as lhcir solc compcnralion, will do thc work ard lhc strelurc is mt <br />irilefuhd or offercd for slc (Sa'.7(X.{, Busincss and Pmfesskns Code: TIE Coillrdck}r's Liccn* hw d@s not spply to an owncr of <br />thcpmpcny whobuildsorimproveslhermil,udwhodoessuchworkhimsclforhcrselforthroughhisorherownemployecs, <br />provid!'d lhat such irnpNverrcnrs ffc mt inlcnded or ollc(1d lbr sle. ll, however. lhL huilding or inprovcrent is sold wilhin onc yctr <br />ofconrplction, the Owrer Buikler will havc th. burden of prcvin8 tlu{ IE or she rlid u builJ or inrpmvc thc prcFEny for thc purpo$ of <br />sale). <br />_1. rs owner ofthc propcny, am erclusively conlrrctin8 with licensed conlrsclos x) construcl llE pNject (Sca. 704.{. Business <br />and PnrltsskDCodc:TheContracktr'sLicenseLawdoesnotapplytounowncrofpropenywhobuild$orinrprovesthercor. <br />and who contracts for such pr(,iccts wilh a Contrack)r(s) liccnscd fursu{nl h lhc Conraclor's Liccnse Law). <br />-l <br />am crempt 0nder Section-. B. & P.C. ti)r this realon. <br />WoRKI.IRS' COM Pl:NSATIoN <br />DT]CLARATI0N <br />I hcreby at'lirh undcr pcnahy of pcrjury onc of thc lbllowing declaraliots: <br />{lhuveand*ill nuintainaCcdilicateofConsentrrSelfiln*treforurrkcrs'conrpensation,as p()videdforhySection3T00ofthe <br />LatDr Codc, for lhc perlbrrurcc oflhe work lor which lhc permil is issucd. <br />F: <br />hnvc'!il{lwilltr)rinlaitrw()rkcrs c(,npensali(}ninsurance,as requiredbySectitn3T00ofthe[-ahorCode,forthelErfornunrceof <br />work lbr this is isrucd. My compcnsation insurrncc carlicr el lx)licy nunrbcr uc: <br />lbliuv 0 '2-O <br />_l ccrity thar in thc pcrti)rnruncc ()[rhc work for which this pcrmit is issued. I shilll not cnrdoy uny lrrson in any manncr <br />*o as lo hccorrE suhjcct to thc workcrs' conpcnsation hws ol'Cali lon)ia, and agrcc lhrt if I slnuld bccorre subjcct lo lhc <br />worlcrs' conrpcnsotion provi\ions of Section 1700 of thc Labor Code. I shall, fonhwith conlPly with tho* provisions. <br />WARNIN(;: Iiililurc !) sccurc wrrkcrs' conlrcnsatrrr covcrrge is tDlilwlil, nn(l kr oiminrl pcnahics and <br />civil fincs up lo onc hundrcd thousand dolhrs ($l{x),(xn),darmgcs as providcd for thc <br />Seer()n ll(176 of rhc tjlatr (i)de. irterest,^"Jlt?lL <br />I l)lt('t.AR.\t t()N <br />I hcrcby al lirm undcr tx:nalry of pcrjury lhal I am liccns!'d undcr provision o, Ch8plcr 9 (.ornrrcncin8 wilh Scction 7fiX)) ol Division 3 <br />of rlc Rusincss and Profcssions C(xlc. fll my liccnsc is in full lirrce iuxl clfect. <br />Liccnsc <br />/,2 <br />I heRby aflirnr trnder JEnaIy ofperi!ry tlrat there <br />issucd (Scc. 1097. Ci!. C.). <br />lf,ndcr's Nnnrc: <br />a8eilcy perfomarrce of rhe work fbr which this pcmrit is <br />lJndcr'r Addrcs\: <br />APPI,ICANT DECI,.{RATION <br />I hercby atrmr under p€nslly of perjury one of thc following declur{tiols: <br />DenDlitiorr Permits-Asbeslos Notification Fctlcral Regulatiorrs (Title 40, Part6) <br />_Required lJttcr of Notificution <br />_l cedity that tlrc fbdcralregulatirDs rcgddinS rstrsbs rcnx)valile nor applicable b rhis prcjer. <br />bn is correcl. I ilsr@ to conrply with rll Cily and County <br />Applicunl or Agctrt <br />aril <br />aulhorize representalives ofthis City and County b eillea uF)n the <br />Set Backs <br />Forms/SteeliHoldowns <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/Eneroy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />fttlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />FINAL ,.L.i-Zo *?lo, <br />Certificate of Occupancy <br />Notes, Remarks, Etc <br />( a[ier