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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG COMMENTS OWNER AUILDER DELCARATION <br />I hcrchy afftrn undcr Jrcnalty of Frjury rhar I .m crcmlr fiom thc Contracto6' Liccns kw for thc followirrg -"o'iii1s*.70.11.5 <br />Busirrcss aul Prolcssion Crx.lc): Any Cily or GruDty which rcquircs a [Ermit lo conslruct. allcr. improvc. dcmolish or rcpair any <br />$lructurc, prirr lo ils issuancc, also rcquircs thc applicsnt f(rr such lrcmit to lilc a signcd statcmnl that hc or shc is liccn*d pursuanl <br />to thc provisions of thc Contrackf's Liccn*d tav (Chaptcr 9, Commcncing wilh Scction 7000 of Division -l of thc Busincss and <br />PmftssionsCor.lc)orthathc(rshciscrcmptthcrchomandthcbasisforthcullcgcdexcmption. AnyviolalionofsetionToJl.5byany <br />applicant li)r a lrcmit subjc.ls the applicant k) a civil Jrcnally of noI morc lhan livc hundrcd dollds (S.50O). <br />_1, as owncr ol'thc propcrty, or my cmployccs with wagcs as lhcir sole compcnsation, will do thc work and thc struclurc is not <br />intendcd or ()ll'crcd lbr salc (Sec.7044, Busincss and Pnrf'cssions Crxle: Thc Contractor's Liccnsc Law drrcs not apply to an owncr of <br />thc prol^-rty who builds or improvcs thcrcon, aml wlx) tkrcs such work himsclf or hcrsclf or tluough his or hcr own cmpk)yecs, <br />providcd that such improvcrncnts arc not intcndcd or oltcred tirr sah. It, howcvcr, thc buiklingr or impn)vemcnt is sokl within onc ycar <br />ol'complction, thc Owncr Buildcr will havc thc burdcn ol'proving that hc or shc did not build or improvc thc propcrty lbr thc purposc ol <br />salc). <br />_1, as ()wncr ol'lhe pK)pcrty, am cxclusivcly contracting with liccttscd corttractors to cottstruct thc projcct (Sec. 7(X4, Busincss <br />and hofbsskrrt Codc: The Contractrlr's Liccnse Law tltrcs not apply to an owncr of profrcrty who builds or improvcs thcreon, <br />and who c()ntracts tor such prcjccts with a Contractor(s) liccnscd pursuant to thc Grnlractor's Liccnsc Law). <br />_l am cxcmpt under ts. & P.C. tirr thrs rcason. <br />Date: Owner: <br />WORKERS' COI}IPENSATION <br />DECLARATION <br />I hereby afl'irm undcr Jrcnalty of pcrjury one of thc lirlkrwing dcclarations: <br />_l havc and will maintain a Certificatc of Conscnt to Sclt-lnsurc lilr workcrs' comJrcnsationr as providcd for by Scctirtn -1700 of the <br />latxrr Crxlc, lirr thc pcrlirrmancc ol'thc work lirr which thc ;rcrmit is issucd. <br />_l havc and will maintain workcrs' compcnsation insurance, as rcquircd by Scction 3700 of thc Labor Codc. lbr the Jrcrtirrmancc of <br />thc work lirr which thi.s Jrcrrnit is issued. My workers' compensation insurancc carricr atxl Jxllicy numbcr arc: <br />,.*r,",, ' 9+.ni<- hnnl <br />Policy \-z /l o/1-o2 I <br />__l ccrtily lhat in thc 1^-rlilrmancc of thc work lilr which this Jrcrmit is issucd. I shall not cmploy any [rcrs()n in any manncr <br />so as to bccomc subjcct to thc workcrs' compcnsation laws of Calitilrnia, and agrcc that il' I should becomc subjcct to thc <br />wrlrkers' compcnsation provisions of Scction 3700 of thc Lahrr Crxlc, I shall, tirrthwith comply with thosc pnrvisiotts. <br />IVARNINO: Failurc to sccure workcrs' comJrcnsation covcragc is unlawtirl. and shall subjcct an cmpkrycr to crirninal pcnaltics and <br />civil lincs up to onc hundrcd thousand dollars (Slm,Uru). in addition to thc cost of conrpcnsation, damagcs as providcd lilr thc <br />Scction .i076 of thc Lahrr Crxlc, intcrest and attorncy's l'ccs. <br />I <br />I <br />I hcreby allu'nr undcr ;rcnalty of prjury that I am liccnscd of Chaptcr 9 (comnrcncing with Scction 7UX)) ol'Divlsion -] <br />ol' thc Busincss anrl Prllbssions Code. arxl my liccnsc is in l'ull lirrcc and cll'cct. <br />,L tto i Ol-iccnsc Nunrbcr: <br />U.1/ <br />W <br />I hcrcby atl'irm undcr [Emlty of Frjury lhat thcrc is a construclion bndirg agercy for lhc lrcrlbmncc of lhc work for which this lrcmit is <br />issucd (Scc. .1097, Civ. C.). <br />lrndcr's Namc: <br />[rntlcr's Addrcss: <br />APPLICANT DECLARATION <br />I lrcrcby afl'rm undcr pcnalty of grcrjury onc of thc following dcclarations: <br />Dcmolition Pcrmits-Asbcstos Notillcalion Fcderal Rcgulations (Titlc 40, Part6) <br />-Rcquircd <br />l-cttcr of Notilication <br />_l cerlily that thc l'crlcralrcgulalions rcgarding ashcstos rcnxlval arc not applicable lo this pr<ljcct. <br />:Z4ccrtrty thar I have rcatl this applicatirln arxt statc that fhc ahrvc inltrrmatiort is conect. I agrcc to contply <br />rlrdinances and Statc Laws relating to huilding construction, and hercby authorizc reprcscntativcs of this City <br />with all City and County <br />antl Counly to cnlcr uJxrn thc <br />atxrve nrcnti()ned propcrty lilr insJrcction purlx)scs. <br />Applicant or Agerrt ..._..-...-- x LD, <br />Pentritee nanre (orinr): {- Lfl,'/\ oc.\ ai: <br />b <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bf loor/VenVl n s u latio n <br />Roof Sheathinq <br />Shear Wall <br />Framing <br />Insu Iation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />lMasonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />I , <br />FINAL ltl 14 l7o DA.Y'7 <br />Certificate of Occupancy I <br />Notes, Remarks, Etc <br />Elarr nP.-n7 -2n 1 q <br />o*",t lo/t / 1p\p <br />i <br />,,r",' Lo///1o2-o