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BUI!-DING. INSPECTOR RECORD SITE.WORK DATE ID/SIG,COMMENTS Owns-Builds Dcclaration I hereby affirm undcr p€mhy of plrjury that I rm exempt form the ContractoB' Liccnsc Law for thc folkrwrng rason (src.?03 I .5 Busintss and ProGssion Codc): Any City or County which rcquira r pcmit to comtrucl. alt6. impreve. dcmolish or rcpair rny structuc. prior,kr its issurncc. also rcquirc thc applicsnt for such pcmit lo filc a signcd stalmnt lhst hc or shc is liccDscd purcuant to thc prcvisiom of thc Cont.actor's Licensed Llw (Chaptq 9, Commcncing with Sction 7flD of Drvision I ofthe Busin63 rnd Prof6sions Codc) or that he or shc is cxcmpt lhefrom and lhc bsb for thc allcgcd cxonption .Any violation ofseclion 70-l 1.5 by any applicant for i ponit subjccts thc rpplicant to a civil pcnalty ofnot morc than tivc hudrcd dollaE ($500). _ l.s owncroflhcpropcrty.ormycmployccswithwag6asthcirsolccompcnsalion,willdolhcwo*endthcstructurcisnotintcndcd or offered for sle ( Se 7044, Busincss and Professions Code: Thc Contraclor's Liccnsc Law do6 ool apply to an owner ofthe prcpcrly who builds o. imprcvG thcron. and who do6 such work himsclfor hc$clfor through his or hcr own cmploys. providcd th.t such improvcments arc not intcndcd or offcrcd for salc. lf. howcvcr. thc building or improvcmcnt is sold within onc ycar ofcomplction. thc Owner-Builder will hsve thc burd.n ofproving that hc or shc not build or improvc for thc purpos. ofsale). _1, as owner of the propefly. arn e.xclusively contracting with licensed conlractors to construct the project ( Sec. 7044. Business and Profession Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon , and who contracts for such projects with a Contractor(s) licensed pursuant to the Contractor's License l-aw ) _-l am exempt under Section Date: .8. & P.C. for this reason. _Owncr: WORKERS COMPENSATION DECLARATION I hcrcby affim undcr pcnalty ofpsjury onc ofthc following dslsrations: _l havc ard will maintain a Ccnificrtc ofConscnl to SclfJf,sure for workers' compensrtion, as provided for by Section 3700 ofthe t bor Codc. for thc pcrfomncc of thc work for which thc p€mit is issucd. _l haveandwill nraintainworkers'@mpensationirsurance,as requiredbySectionlT0oofthet,aborCodqfortheperformnccofthc work for which this pernrit is issued. My workcrs' compenstion insurancc canicr and policy numbcr arc: Carrier:_ Policy Number:_ _E.xpires: (This section need not be completed if the permit is for One hundred dollars {$100} or less) #hrffiat in the performance of the work for which this permit is issued. t shall not employ any person in any manner so as to ' became subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section .1700 of the Labor Code. I shall. forthwith comply with those provisions.. _Applicant: WARNING: Failure to seure workcrs' compensation coverage is unhwful. snd shrll subjst an employer to siminal pcnaltics ard civil fines up lo onc hundrcd thousand dollaE ($100.000).in addtion to thc cost ofcompcnsation. darnagcs as provided for thc Strtion 1076 of the Labo. Codc, interet and attorney's fc. LICENSED CONTRACTORS DECLARATTON I hcrcby atfim undcr pcnnlty of pcrjury that I am liccnscd undcr prevision ofchrptcr 9 (ommcncing with Scction 7000) of Division 3 of thc Busin6s and Prof6sions Codc. and my liccNc is in full forcc and cffcct. [,icense Class:23263L B,c{.f.*u,no*Y32632 "",,7/// ?_Contractor: CONSTRUCTION LENDING AGENCY I h(cby aflim undcr pcnaly of pcrjury lhat th.rc is a coEtruction lcnding rgcncy for thc pcrfomncc of thc work for which this pcrmit is issucd (Sc. 3097. Civ. C.). Lender's Name: Lender's Address: - Dcmolition Pcmits-Asbestos Notitication Fcd.o, *ffititffiffi _ Rcquircd lrttcr of Notification _l ccnify that thc fcdcralregulstions rcgarding 6b6tos rcmovalarc not npplicablc to this prqiet. ,€i;i$,-an", , *vc rcad this application and sratc rhar rhc abovc infomarion is conccl. I rgrcc to comply wirh 8ll City and county ordimncG and Statc kws rclsting to building comtruction. ed hcrcby authoriz rcprBcntrtivB ofthis City and County to otcr upon thc abovc mcntioncd propcny for inspation purposc. Applicant or agenl _Date: Pcrrnittee narrre (print ):-.s--_r,*C Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Subfloor/VenUInsul Roof Sheathing ^t//ff-T ll-Qc ^l,q KlZt) Shear Wall ( Framing lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif FINAL Certificate of Occupancy Notes, Remarks, Etc. Forms\Building-lnspection Record.doc 03.31.06 ,!