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BUILDING. INSPECTOR RECORD <br />Rev.08-0/-2015 <br />SITE.WORK DATE ID/SIG.COMMENTS owNER lrt,il,t)uR t)t:t,cARATtoN ,t <br />I hecby affirn undcr pcnahy of perjury that I mr excnrpt from the CbntracloB' LiceDse Iiw for the followint rcasn (Scc.?031.5 <br />Busrncss ind Professir)n Codc): Any City or Counly which rcquircs a l--rmit h con{ruct, nlter. irnprove. dcrmlish or runair any <br />strucrure,priortoits issuance.alsorequircslheapplicilnttorsuchp€rmilk,tileasigiledslatamnl lhatltorsheislicensd pilrsuanl <br />lo thc pmvisions of lhc Contractor's l-iccnscd l-aw (Chrptcr 9. Cornrncncing wilh Scction 7(x[ ol'Division 3 of lhc Busincss and <br />Prolcs\ionsCode)orthathcorsheiserempltherefiomandlltbasisti)rlltullegedexemption. AnyviolaltrlofSeclion?03l.5hyany <br />npplicnnt for r pennit sub.iects the rpplicanl Io a civil pcruhy of nol rmrc lhiltr live hundrcd dollars ($5{x)). <br />_1. as owncr ol thc proFny. or my crnployccs with waSes <br />^s <br />thcir $lc compcnsation, willdo thc wtrk and lhc slMture is not <br />iuemled orofferedlirrsule(S*.7(N4,BusinessnndPnrfcsstrtsCodeiThe(i)ntrdclor'sl-icenscLawdoesnolrpplyloanownerof <br />thepfl)pcay whotNildsorimplovcstherdnLandwk)docssuchworkhinrsellorherselfortlroughhisorherowncmployees. <br />providcd lhat such impn)vcmnts ee ml inlcrdcd or oll'crcd ,'or slc. ll. howcvcr, tlr tuikling or irrprovcDnl is soL wilhin onc yctr <br />ofconplcli)n. the OwrEr Buil&)r will luve lh. bunlen ofpruvin8 lhxt lE or she rlid mt boild or impnrve tlrc pnr;rny for the purF)* of <br />Mle). <br />_1. {s owner of lhe roperly. am exclusively conlracting wilh licensed conlrAclors to conslrucl lhe prejecl (Sec. 7(}44. Business <br />and Pnrli'ssirnCode:TheCr)trtractor's[-iceDseLawdoesnotapplytoanownerofpropeflywhobuildsorinrprovesthercotr. <br />and who coilracls[rtr\trchprojcctswithnContrrctor(\)liccnscdpur\uinllolhcComrrctor'sLiccnse[jw). <br />_l im exempt under Secti<xr-, B. & P.C. tor lhir rea\on. <br />woRKt:Rs' col\fl,t)NsA'iloN <br />t)!:ct-ARA'l't()N <br />I hcrchy allirm p!nahy ofpcr.jury onc ol thc tbllowing dcclarations: <br />-I <br />willnriintriunCe(iticaleof(lnrsent()Selflnsureftrr*orkcrs'conrpetrsati()n,as prcvidedforhySectionlT00ofthe <br />li,r pcrlormancc ol'thc work Ior which lh! pcrmit i\ i\sucd. <br />required by Scction 3?00 oflhe tibot for the lErfomENc ofhave !trd <br />rhc worl li)r inl F)[cy numhlr <br />Policy <br />_l ccnily for which this pcrmit is issucd, I shrll not cnrploy any pcrson in aoy manncr <br />so as to hccorrc suhjrcl h lhc workcrs' coillpclsation laws ol Cnli fonria. and agrcc thal if I should hccorrc subjcct lo the <br />workers' eonrPensation provisions of Section 3700 of rhe Lahr Code, I shrll. fonhwith conrply wil h lhoF provisions. <br />WARNINGT Failure rr sccurr. workers'c()mpcnsation covcrugc is unlawful. and shall suhjcct nn emphyer to dminll Fmltics and <br />civil fincs up to one hundred thousand dollars (51fi).(Xn), in additio[ to damSes as providcd for lhe <br />Secti(D J076 ofrhe (,ixle, fuilerest <br />I)t.t( t_,\R,\t t()N <br />I herchy allirm undcr pcnalty of pcrjury lh4 I am liccn$'d undcr provision ol Chaptcr 9 (cornrmncing wilh Scction 7fi)O) oI l)ivision 3 <br />of thc Busincss ild Pmfcssio$ Code. 8l mv liccns is in full ti)rcc atul clt'cct. <br />Liccnsc Nurnlrr: <br />I heBhy atlirft under lEnaltyof perjury tlut theE is a constructiol lendirg a8errcy fbr the lErfomrce of thc work tbr which llis FEmit is <br />issucd (scc. 3097, Civ. C.). <br />Lxndcr's Narnc' <br />kndcr's Ad,lress: <br />APPLICANT DECI,ARATIoN <br />I lEreby nffiml under lxnrllv uf perjur) onc of lhe followi,l8 declaritions: <br />DcnrclitioD Permits-Asbr\tos Notification Iederal Regulillions (Title.l0, Prf,6) <br />Rcquircd IJtler of <br />_l cetr fcderal rcSulations rc8udin8 asbest)s ren$val are not applicable to this proicct. <br />lhrl I hrvc rcn(l applicdlion Ind stale lhat lhc above infomuliur i\ corccl. I agr.c to comply <br />represcntnlives r)t lhis City <br />with all City and County <br />rnd Co!illy to cilter uF)il therild State l-aws <br />utx)vc nNori()ncd <br />Applicont or Agcnt <br />Pctmitc( trunrc <br />to buildiilg coilstructi()n, rtrd hercby auth(!rize <br />,^,.7/'.% <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 />lnsulationiEnergy <br />Drywall I iltAlru WLv-tR-"?/n/ <br />Ext./lnt. Lath rr I I I <br />Brown Coat <br />ltllasonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputv Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />,,.- <br />FINAL A/qho (,Lra\i,r '/{C/ <br />Certificate of Occupancy U <br />Notes, Remarks, Etc..4---}. <br />I <br />-----I r I r ul <br />L. <br />I <br />VLnEr, *O)"rlt*llzt 'nrld--l <br />-J <br />\