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BUILDING- INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG.COMMENTS <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf Ioor/Vent/l nsu lation <br />Roof Sheathinq <br />Shear Wall , <br />Framinq nl1s,lfu)Dl\nhr t#f,| <br />!nsu lation/Enerqy I lr <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />[t/asonry <br />Poo! Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />F!NAL zl t1ltp -F>*+*t <br />I n-.VW <br />Certificate of Occupancy I /I I <br />NoJes, Remarks, Etc. <br />I hereby affirm under penalty of JErjury that I m excmpt fmm thc Coilractom' Liccnrc Law for thc following rcason (Scc.703 1.5 <br />Busincss ard Protbssion Codc): Any City or County which requircs a Jrcnnit to conslrucr. altcr, improvc, dcmlish or rcpair iiry <br />structure, prior to its issuance. also rcquircs lhc applicant for such lrcrnrit to filc a signcd statcrrcnt lhal he or shc is liccnsd pursuant <br />to thc prcvisions of thc Conracto('s Liccn*d ljw (Chaplcr 9. Commcnchrg with Scclion 7000 of Divi*i)n 3 of lrr,' Business srrd <br />ProfcssionsCodc)orthathcorsheisexcmptthcrcfromandlhcbasisforlhcallcgcdcxcmFion. AnyviolationofscctirnTi3l.5byany <br />applicant for a pcrmit subjccts thc applicant to a civil pcnalty of nol morc than five hundrcd dollds ($500). <br />_1. as owncr of the ()r willdo thc work and thc structurc is not <br />License Law does not apply to an owncr ofintcndcd or offcrcd frrr <br />thc proprty who builds or and who docs such work hirnsclf or hersclf or through his or hcr own crnployces. <br />providcd that such are not intcnded or offercd for salc. If. howcvcr. thc building or improvenrent is sold within onc ycar <br />of cornpletion.Buildcr will have thc burden of proving that hc or shc did not build or inrprovc the propcrty for thc pur;nsc of <br />sale). <br />of the property. ant cxclusivcly contracting with liccnscd conlractors lo construct thc projcct (Scc. 7M4, Busincss <br />and Pnlfcssion Codc: The Contractor's License Law docs not apply to an owt'rcr of property who builds or improves thcreon. <br />and who contracts for such projects with a Contractor(s) licenscd pursuant to thc Corttractor's Liccnsc Law). <br />-l <br />arn cxcnrpt urrdcr B. & P.C. tbr this rcasotl. <br />DI,l(:1.,\RA'l'l()N <br />I hereby affirm undcr penalty of perjury one of thc dcclaratiotts: <br />_l have and will maintain a Certificatc of Consent to Sclf-lnsurc lbr workers' compensation. as providcd for by Section 37fi) of the <br />Labor Code, for the pcrformance of thc work tbr which the permit is issucd. <br />_l have and will maintain workers' conrpensation insurancc. as rcquired by Sect ion 3700 of thc Labor Codc. for thc perf<lrnrance of <br />thc work for which this permit is issued. My workers' compensation insurancc carrier and policy number arc: <br />Policy <br />certify that in the pcrformancc of thc work for which this perrnit is issucd. I shall not cnrpkry any pcrson in any tnanncr <br />so become subjcct to thc workcrs'cornpensation laws of California. and agrec that if I should bccotne subjcct tothc <br />workers' compensation provisions of Scction 37fi) of the Labor Code. I shall. lbrthwith comply with those provisiotts. <br />WARNING: Failurc to secure workers' contpensation covcragc is unlawful. and shall subjcct an entployer to crinrinal pcnaltics and <br />civil fincs up to onc hundrcd thousand dollars in addition to the cost of conrpcnsation.darnages as providcd for thc <br />rScctiorr 3076 of thc Labor Code. intercst and <br />l)ECLAlt,\'l'lON <br />I hcreby atfirm under pcnalty of pcrjury I ant liccnscd undcr provision of Chaplcr 9 (conrnrcncing with Scction 7fiX)) of Division 3 <br />of thc Business and Professions Codc. and my liccnsc is in l'ull fbrce artd elfect. <br />Liccnse Class: Licensc Number: <br />CONS'I'RI,]C'I'ION I,IiNDIN(; A(;IiNC}' <br />I hcrcby afnrm undcr Fnaltyofperjury thot therc is a construction lcndirg agcncy for thc performncc ofthc work for which lhis Jrcnnil is <br />issucd (Scc. 3097, Civ. C.). <br />lrndcr's Name: <br />lrnder's Address: <br />APPLICANT DBCLARATION <br />I hcrcby aflirnr undcr penalty of pcrjury ortc of thc lbllowing dcclarations: <br />Dernolition Perrnits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40. Part6) <br />Rcouircd Lettcr <br />-I <br />thc fcdcralrcgulations rcgarding asbcstos removal arc not applicablc to this projcct. <br />ordinanccs <br />with all City and County <br />and County to entcr upon thc <br />ab<lve <br />Applicant or <br />Pcrnrilee <br />[or purposes. <br />"",7 15 -2t'Z> <br />I