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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE !D/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcrchy atlirm undcr pcnalty of Frju]y that I am cxcmpt hom thc Grnlraclors' Liccn* law li)r lhe foll(rwing rcasrn (Se.703].5 <br />Busincss ail Profcssion Gxlc): Atry City or County which rcqutcs a Frmit k) construcl. altcr. improvc. dcmolish or rcpair any <br />structurc. pri)r to its i$suancc, also rcquircs lhc applicant for such lErmit k, filc a signcd statcmnl that hc or shc is lictnsd pusunl <br />to thc provisions of thc Gnrlractor's Liccnscd Law (Chaptcr 9, Commcncing with Setion ?0U) of Division -1 of thc Busincss and <br />Prufcssions Codc) or thdt lE or shc is cxcmpt thcrcfrom and thc hasis for thc allcgcd cxcmptiul Any violalion of Setion 70.1 1.5 byt any <br />applicant li)r a lEmit suhjccts thc applicant to a civil pcnalty of not n$rc than livc hundrcd dollrs (5500). <br />_1, as owncr of thc propcrty, or my cmployccs with wagcs as thcir solc comfrcnsalion, will do thc work arxl thc slructurc is nol <br />intendcd or ol'fcred filr salc (Scc.7044, Busincss and Prol'cssions Crxlc: The Contractor's Licensc l-aw docs not apply to an owncr of <br />thc pnrJrcrty wlro builds or improvcs thcrcrrn, and who drrcs such wrlrk himsclf or hcrscll or thr)ugh his or hcr own cmpk)yccs, <br />provided that such improvcrncnts arc not intcrxletl or ollbrctl tilr sah. Il, howevcr. thc huikling or improvemcnt is sokl wilhin one ycar <br />of comphtion, thc Owncr Builrlcr will havc thc burdcn ol'proving that hc or she did not buikl or improve the pnrpcrty lirr thc purprsc o[ <br />salc). <br />_1, as ()wncr of thc pn)pcrty, am cxclusivcly contracting with liccnscd contractors to conslruct thc pnrject (Scc. 7044, Busincss <br />and Pnllbssion Code: 'fhc Contractor's Liccnse Law tlocs not apply lo an owncr of propcrty who builds or imprtlvcs thcrcon, <br />and who conlracts lirr such projccls with a Contractrlr(s) liccnsctl pursuant to thc Contract()r's Liccnse Law). <br />-IamcxcnlptundcrScctitln-'B.&P.C.lilrthisrcasrln'f \..a ^. <br />WORKERS' COTII PENSATION <br />DECLARATION <br />I hcrcby alTirm undcr Jrcnalty of prjury onc of thc lblkrwing dcclarations: <br />_l have arxl will maintain a Certiticatc of Consent to Sclf-lnsurc lbr workcrs' comSrcnsation, as providcd tirr by Scction 37fi) of thc <br />l^V, Crxlc. lbr thc pcrlirrmance of thc work for which thc pcrmit ls issucd./ <br />{t luu" and will maintain wrlrkcrs' comJrcnsation insurance, as rcquircd by Scctiort 3700 of thc Labor Cotlc, lilr thc perlirrmancc of <br />ill work tilr which this Jrcrmit is issucd. My workcrs' conrfrcnsation insurancc carricr and pllicy numbcr are: <br />3-2o.:. 1\3Policy <br />_l ccrtity that in thc Jrcrlilrmancc of thc work tirr which this Jrcrmit is issucd, I shall not empkry any pcrson in any manncr <br />so as lo hccomc subjcct to thc workcrs' compensation laws of Calilirrnia, and agree that if I shoukl become subject to thc <br />workcrs' comJrcnsation provisions of Scction 3700 of thc Latxrr Crxlc, I shall, forthwith comply with ttxlsc pnlvisions. <br />WARNIN(i: Irailurc to sr'curc workcrs' crtmpcnsation covcragc <br />civil lincs up to onc hurttlrcd thousantl dollars ($1fi),Ot)O), in <br />is unlawful, anrl shall sub.jcct an cmploycr trt criminal Jrclraltics and <br />addition t<l thc cosl ol'compcnsation, damagcs as providcd lirr thc <br />Scction .t07(r ol'thc Lahrr Ctilc.zrq intcrcst and attonrcy's t'ccs. <br />2 <br />I hcrcby at'tirm under Jrcnalty of Jrcrjury that I am liccnscd undcr Chaplcr 9 (comnrcncing with Scctkrn 7m0) of Division 3 <br />of thc Busincss and Prol'cssions Crxle. arxl my liccnsc is in full tirrcc arxl etl'cct. <br />Liccnsc C-Numbcr:tOr-{ zZ\\-( <br />Date: 1- o-* Z\e t <br />W <br />I hcrcby afftrm undcr lEnalty of lErjury thot thcre is a constructi)n lcnditrS agerey for thc lErfomrec of lhc uork for which this lrcmit is <br />issucd (Ss. 1097, Civ. C.). <br />[,cndcr's Namc: <br />lrndcr's Address: <br />APPLICANT DECLARATION <br />I hcrcby atlirm undcr penalty of perjury onc of thc folkrwing dcclarations: <br />Dcmolition Permits-Asbcstos Notification Federal Rcgulations (Titlc 40, Part6) <br />_Rcquircd l,ctter of Notilication <br />/ Lcrtity that thc l'ctlcral regulations rcgartling asbcslos rcmoval arc not applicablc to this projcct. <br />/ t certifythat I have rcarl this application arxl statc that the above intormation is corrcct. I agrcc ro comply wirh all City and Counry <br />ordinanccs and State laws rclating to hcrcby authorize rcprcscntativcs of this City and County to entcr upln the <br />ahrvc mcntulncd pmJrcrty lilr <br />Applicant or Agent <br />Pcnrritee nanre <br />construclion, aml <br />3 rd 2ci.r <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bf loor/Ve nVl n s u Iatio n <br />Roof Sheathinq t tl Lol1,0 Dft*31 <br />Shear Wall <br />Framinq <br />lnsulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />[Vlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif. <br />I l--, <br />FINAL // /t z/ao - t,l-\t(Certificate of Occupancy <br />Notes, Remarks, Etc. <br />Florr n9,-n7 9n 1 q <br />I nrirrl l:n:€ o..\nracr.Zo.(-.. ,