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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS ()WN I.lR Il t, I l,DI.,lt I)F:LCA RAl'l( )N <br />I hereby affrrnr under penalty of perjury that I am exempt fronr the (:ontraclo$' l-icense l-aw for the following reason (Sct'.7031.5 <br />Busincs.s and Prolbssion Codc): Any City or County rvhich rcquircs a 1o-rrnit to construct. altcr. irnprovc, dernolish or rcpalr any <br />structure. prior to its issuance. also requires the applicant fi)r such permit to file a signed slalenrenl lhat lrc or she is licensed pursuanl <br />to thc provi.sions of thc. Contractor's l,icenscd l.aw (Chaptcr 9, Comrncncing with Scction 7(XX) ol' l)ivision 3 ol'thc Bu.siness and <br />Prol'essionsCrxle)ortlratheorsheisexemptthereftonrandthcbasislirrtheallegedcxenrptiou. AnyviolatiortofSectionT03l.5byany <br />appliclnt for a pcrrnit subjects the applicarrl to il civil penalty oI not rnore thurr five hundred dollars ($5tXt1. <br />,/fr.as owncr ol'thc properlv. or my crnployccs with wages as rhcir solc cornpcnsation, wilt do the work ard thc stnrture is nnt <br />- fntenderl or offeretl for sale (Sec'.7O1.1. Business and Prcfessions Cotlc: The Conlractor's License Law ttoes not apply to an owner of <br />the pnrpcrly wlm builds or improves lhereor\ und who does suclr work hinrself or herself or through his or her owu enrployees. <br />providcd that such irnprove'nrcnts arc rnl intcndcd orollbred l'or sah. Il. houcvcr. thc building or improverrEnt is sold withinone ycar <br />of conpletiun, the Owrrcr Builtler will lurve thc burden of proving that hc ur she tlitl not build or improve the propcny for tlrc purlnse of <br />%-.ilxs:'J:Tii'llr;r};l;rillr;"ili'il:,xriffil::l:::iff::':li:rilfilil::r,::]ff.f,ri;liTl;m'ffi: <br />and who conlracts lor such projccts with a Contracto(s) liccnscd pursuant to thc Contracl()r's Liccnsc Law). <br />-l <br />anr excnlpt under B P.C. lirr <br />t <br />l)r:('l,ARAI'l( )N <br />I hcrcby all'irm undcr penalty of pcrjury one of the ttrllowing dcclarations: <br />-lhaveantlwill <br />nuintainaCertificateofCormenttoSelf-lnsuref<rrworkers'compensation,as prcvidedforhySection3T00ofthe <br />Lahor Ctxlc, [<rr thc Jrcrformancc ol'the work lirr which thc pcrmit is issucd. <br />_l have and will nraintain workers' compersation insurance, as required by Section 3700 of the Labor Code, for lhe perfornutrce of <br />thc work tbr which this pcrmit is Lssucd. My workcrs' c'omJrcnsation insurancc carricr urxl plicy numbcr arc: <br />Carrier: <br />Policy <br />eAccrrity that in thc 1^-rtirrnunce of thc work for which this pcrnrit is issucrl, I shlll not cmploy any pcrson in any manner <br />so aslotrccornesubjccttothcworkers'corlrpcrrsationlawsofCalil'onria.andagrccthatil'lshouldbecotncsubjccttothc <br />workers' conr;rcnsation provisions of Section 3700 of the Labor Cotle, I shall, forthwith conrply with thosc provisiorts. <br />IVARNING: Failure ro sccurc workcrs' contpcnsation covcftrgc ls unlawful. antl shall subjcct an cn4rloycr to criminul Jrcnahics antl <br />civil lirres up to onc hundred lhoustnd dollars ($l(X),(XX),1. in addition to lhe cosl ol'ion. damages as provided lbr the <br />allorney's <br />I <br />DECT,ARATION <br />I hcrchy al'lirrn undcr pcnalty ol'pcrjury that I arn liccnscd undcr provision ol Chaptcr 9 (cornrnencing with Scction 7(XX)) ol'l)ivision 3 <br />of thc Busincss and Profcssions Crxlc. antt nry liccnsc is in full lirrcc urul clll'ct. <br />License Class: License Nurnbcr: <br />CONS'I'RT)C'TION I.}:NI)ING AG T:NCY <br />I trereby aflirnr under pnalty of per.iury that there is a c()nstnrction lerxliug agerrcy lbr the pertirrmarrce o[ lhe work lirr which this pmtit is <br />issuctl (Scc. 3097, Civ. C.). <br />Lcrdcr's Narnc: <br />Lcnrlcr's Arklrcss: <br />APPI,ICANT DECI,AR,,\TI0N <br />I hcreby affrnr under pnalty of prjury one of the following decluratiorrs: <br />f)enrolitiorr Permits-Asbestos Notification Fetleral Regulatiorrs (Title 40, Part6) <br />_Rctluircd Letter of Notilication <br />with all City and County <br />and County to enter up)n tlE <br />irhor,c rrrcntirlncrl propcrry firr <br />(,\pplicant or ltgcnt <br />('rnnitce nanre <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenVI n su I atio n <br />Roof Sheathing <br />Shear Wall <br />Framing <br />lnsulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />lt/asonrv <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />-t I ^ <br />F!NAL il'lZ,E ILC$tt le(*g vLll <br />Certificate of Occupancv <br />Notes, Remarks, Etc. <br />Rev.0B-07-2015 <br />I