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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby affum undcr pcnalty ol Frjury thd I m cxcmpt t'rum thc Conlraclon' Liccnsc tlw for lhc followinS rcasn (Sbc.70ll.5 <br />Business anl Profcssion Cillc): Any City or County which rcquircs a Frmit lo construcl, allc( imprcvc, demlirh or rcl[ir any <br />slruclurc. Irk r to ils issuarcc, also rcquircs thc applicanl lbr such pcmit lo lile a signcd stalcmnt lhat he or she k licensd puFuel <br />t(, thc pn vlsions of thc Contraclor's Liccnsd law (Chaptcr 9, Commencing with Se-tbn 7fiX) of Division 3 of lhe Busircss dd <br />Pnrfcssions Codc) or that he or shc is cxcmpl thscliom od lhc basis for thc allcgcd crempltun. Any violation of Scatbn 703 1.5 by any <br />applicant lbr a tEmit subjccts lhc applicant to a civil pcnalty of not mrc lhan five hundrcd doll[s (S500). <br />_1, as owncr ol'the pn)pcrty, or my cmployccs with wagcs as thcir solL'conrpcnsation, willdo tlrc work antl thc stru,cture ls not <br />intcntlcd rlr otlcrcd for salc (Scc.7(X4. Busilrcss and Pnrl'cssions Codc: Thc Contraclor's l-icense [-aw docs not apply lo an owncr ol' <br />thc pnlJrc(y who builds or inrprovcs lhcrcon, anrl who rJrrcs such work himsclf or hcrscll'<lr lhnlugh his rlr hcr own employccs, <br />providcd that such impnrvenrcnls :rrc not inlcndcd rlr ollbrcd ftrr salc. lt, howcvcr, thc huikling or inrpnrvcnrcnl is sokl within onc year <br />of conrplclion, thc Owncr Buildcr will havc thc hurrlcn of pnlving that hc <lr shc did not huild or intprovc lhc pnrpcrty fbr thc purJxrscol' <br />salc). <br />_1, as owner of thc propcrty, am cxclusively cuntracting with licenscd conlraclors lo construct lhc pnrjc'ct (Scc. 7M4, Busincss <br />and Pnrtbssion Ctxlc: Thc Contraclrlr's Liccnsc Law docs not apply to an owncr ol'propcrty who huilds rlr improvcs thcreon, <br />and wlro contracts tirr such projccts with a Contraclor(s) liccnsed thc Contract<lr's Liccnsc Law). <br />_l am exempt undcr B. & P.C. lbr <br />a. <br />ft^ a ^.2-_\ \ _ t1 <br />I hcrchy all'irm undcr Jrcnalty ol'1*-rjury onc ol'thc lirlkrwing dcclaralions: <br />_lhavcrurdwillmaintainaCcnilicatcol'ConscnlloScll-lnsurefbrworkcrs'comlrcnsation,as providcdtilrbyScctklnJT00ofthc <br />Latxrr Ctxle, for thc grcrtirrnrancc of lhc work lirr which thc Jrcrmit ls issucd. <br />_l havc and will maintain workcrs' cornpcnsation insurancc, as requircd by Scclion -17(X) ol'lhc Labrlr Codc, lilr thc perttlrmancc of <br />thc wrlrk lilr which this pcrmit is issucd. My workcrs' compcnsalion insurancc carrier urd Jmlicy numhcr arc: <br />Policy Number: Expires: <br />_l ccrlity that in the Jrcrlilrnuncc of thc work lirr which this pcrmit is issucd. I shall nol cmpkty any lrcrson in any manner <br />so as to bccome subject to thc workcrs'conrpcnsation laws of Calilbrnia. <br />workcrs' comJrensation pruvisions ot'Scclion .17fi) ol'thc Latxlr CrxJe. I <br />thal il'l should hccomc subjcct to thc <br />with ttxrsc pnlvisions. <br />IYARNING: Failurc to sccurc workcrs' comlrcnsalion covcrasc is shall subjcct an cmploycr lo criminal penaltics antl <br />civil lincs up to one hundrcd thousand dollars (S100.(Xn), in addition cost ol'conrJrcnsation, damagcs as providcd tilr the <br />:":2x <br />of the Latxlr Ctxlc. inlcrcst antl attorro-y's l'ccs. <br />-\(- t<i <br />I hcrchy al'lirm unrlcr pcnalty ol'pcrjury thal t anr licenscd undcr pnlvision ol'Chaptcr 9 (comnrcncilrg with Scction 7UX)) of Division J <br />of thc Business and Prol'cssions Codc, and my liccnsc is in firll tbrce and ctlcct. <br />Liccnsc Class: License Numbcr: <br />Dale: Conlractor: <br />W <br />I hcrcby alftrm under lEn{lty of [Erjury that thcrc is a conslruclion hndin8 aScncy for lhc lErlbrroncc of lhc M)rk lbr which lhis lEmit is <br />issucd (Scc. J(x)7, Civ. C.). <br />lrndcr's Namc: <br />[,cndcr's Address: <br />APPLICANT DECLARATION <br />I lrcrchy allirm undcr pcnalty ol'pcrjury onc ot'lhc tirlklwing dcclarations: <br />Dcrrxllition Permits-Ashcslos Notil'icatiorr l:cdcral Rcgulations ('fitlc 40, Pan6) <br />_Rcqu ired Let ter ot' Not ilicat iorr <br />_l ccrtit_v that thc l'cdcral rcgulalions ashcstos rcnxrvalitrc not applicahlc lo this projcct. <br />_l certity that I havc reatl this application that lhc ahrve intilrnralion is correcl. I agrcc to comply with all City antl Counly <br />rlrdinanccs and Statc Laws relating to anr.l hereby auttxlrizc rcprescntativcs o[ this City ar! County to enlcr uJnn lhc <br />ahrvc nrcntioncd propcrly tirr <br />Applicant or Agent <br />Pennitee nanre cl; <br />rL..a. a- -t\-\1 <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenVI nsu Iation <br />Roof Sheathing <br />Shear Wall <br />Framing <br />lnsu lation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />lVasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />I I .l ,4, <br />FINAL L n 5ruJ L-/ <br />Certificate of Occupancy -I T T <br />Notes, Remarks, Etc. <br />'lt <br />Y