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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG COIVIMENTS OWNER BUILDER DNLCARATION <br />I herchy affirrn udcr pcnalty of lrcrjury lhal I dn cxcmpl fiom thc Conlrnclors' Liccns law for lhc following rcasn (Scc.70-11.5 . <br />Busincss srd Profcssion Codc): Any City or County which rcquires a lErilril to construct. altcr improvc. dcmlish or rcpir tny <br />slruclurc. prior to its issuancc, also rcquires lhc applicant for such Frcrmit lo filc a signcd slatcmnl that hc or shc is liccnsd pursu.nl <br />to thc provisions oflhc Conlractor's Licenscd Law (Chaptcr 9. Cotrtrncncing wilh Setion 7000 ofDivision 3 oflhc Busincss and <br />PrcfessionsCodc)orthrlhcorshciscxcmptlhcrcfromudthcbasisforthcallcgedcxcmption. AnyviolationofSethn?O3l.5byany <br />applicanl lor a pcrmil $uhjccts lhe applicant ft, o civil pcno[y of nol trorc lhan fivc hundrcd dollars ($50O). <br />_1. as owtrcr of thc property. or my cmployccs with u,ages as lheir solc conlpcnsalion. willdo the work and thc stnrturc is not <br />intcndcd or olTcrcd frrr salc (Scc.7(X4. Ilusincss and Profcssions Codc: 'l'hc Corttraclor's Liccnsc Law docs not flpply to an owncr of <br />the pmpcrly who huikls or intproves thcrmn. aml who rltrcs such work hinrself or hersclf or through his or her own employces. <br />providcd that such inrprovcrncnts arc nol inlcndcd orollbred for sah. ll. howcvcr. thc building or itnprovcment is sold wilhin onc yeiu <br />of conrplction. lhc Owncr Buildcr will have thc burrlcn ol'proving lhat hc or she did not huild or intprovc thc proJrrty for the purf)sc of <br />sah). <br />_1. as owner of thc propcrty. am cxclusivcly contracting with liccnscd contractors to construct lhc projcct (Scc. 7M4. Business <br />and Pnrfcssion Code: Thc Contraclor's [-iccnsc Law docs not apply lo an owner of proJrcrty who builds or improves thercon. <br />arrd who corrlracts lbr such projccts with a (lorrtraclor(s) liccrtscd l)ursuanl lo thc Liccrtsc l-aw). <br />I ant cxclntrl turtlcr <br />,-"r S lE- <br />B. & ['.C. forltt- <br />DFCLARTTTION <br />I hercby alTirrn undcr pcnalty of pcrjury onc o[ thc following dcclarations: <br />-lhaveandwill <br />maintainaCertificateofConscrrtto.Self-lrrsurcf'orrvorkcrs'comgrcnsation.as providedforbyScction3Tfi)ofthc <br />Labor Codc. frrr lhe Jrcrftrrmancc of the work for which the prrnit is issucd. <br />_lhavcandwill maintainworkcrs'cornJrcnsationinsurance.as rcquircdbyScctionlT00ot'thc[aborCode.forthepcrfornuncetlf <br />thc work for which this pcrmit is issued. My workcrs' compcnsali<ln insurancc carricr and Jnlicy numbcr arc: <br />Policy Numbcr: Expires: <br />_l certify that in thc pcrfornulrce oIlhc work lbr which this pcrrnit is issucrl. I shall n<lt cmploy any person in any lllilnncr <br />so aslo bcc<lrnc subjcct lo lhc workcrs'cornpcnsalion laws of Californiu. and agrce lhal if I should bcconrc subjcct to lhc o <br />rvrlrkcrs' conrpcrrsalion provisions o[Scction .]7(D of thc L:rhrr Ctdc. I shall. lirrthwith with thorc provisions. <br />WARNIN(l: I;tilurc to sccurc workcrs' cottt;lcnsatiolt covcragc is an cnrploycr l<l crirninal pcnatics and <br />civil lincs up to one hundrcd lhousarrd dollars (Sl(X).mO). in addition to cost compensation.lor lhc <br />Sccliott .l07(r ol allorncy's a <br />O^t", .. 8 <br />I hcreby alfirnr undcr pcnalty of pcrjury that I arn liccnrcd undcr provision of Chaptcr 9 (comrncncing with Scction 7Un) of Division 3 <br />of thc Busincss and Professions Codc. and rny liccnsc is in full fiorcc and cll'cct. <br />Liccnse Class: Liccnse Number: <br />Date: Contractor:- <br />W <br />I hercby affirm undcr pnaltyof Frjury thut thcrc is a consrruction hnding agcncy for thc Jufonmrcc of lhc work for which this Ismil is <br />issucd (Scc. f097. Civ. C.). <br />[f,ndcr's Narrc: <br />l.cndcr's Ad<lrcss: <br />A PPLICAN'I DECLARATION <br />I hereby aflirm under pcnalty of pcrjury onc of the following dcclarations: <br />Demolition Pcrnrits-Ashcstos Nolificalion Fcdcral Rcgulations (Titlc 40. Parl6) <br />-Rcquircd <br />Lctter of Notilicatkrn <br />_l ccrtify that thc f'cdcral rcgulations rcgarding ashcslos rcnxrvalarc not applicablc lo this pr<ljcct. <br />_l ccrtily thal I havc rcad this applicatiorr ancl state'that thc ahrvc inlirrrttatiott is con'ccl. I agrcc to cornply <br />ivcs o[ this City <br />with all City and County <br />and County lo cnler uJrcn thcorrlinanccs and .Statc [-rws relating and hcreby authorizc rcprcscnlat <br />abovc nrcrrlionccl propcrty tbr <br />Allplicarrt or,\genl ?k-)*rr,'A '9 ' 11 <br />Set Backs <br />Forms/Steel/Holdowns D**C /tlt <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf Ioor/VenVI nsu lation <br />Roof Sheathinq \I I - raAtl fr) <br />Shear Wall \/uxl'-wI l-\--- <br />Framing /\J <br />lnsulatio nlEnerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />JVlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif.I <br />4.fta*".0,J I <br />lll J <br />-,FINAL ,24 ) <br />Certificate of Occupancv \J \ \-/ <br />Notes, Remarks, Etc. <br />Pernriree name tnn"fi- <br />aa^lz& <br />l <br />i-aauio,r r