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BUILDING- INSPECTOR RECORD <br />SITE-WORK DATE ID/S!G.COMMENTS ffi <br />I hcrchy attirm undcr pcmtryT.,t !*;ury r# I ; "i"rp, t'L,n rhc CirntracklN' Liccnsc Law for lhc following rca$rn (Sec 70-11.5 <br />llusincss and Prolession Cdlc): Any Cily or C(rutrly which rcquircs a Frmit k) coNtruct. altcr, impnrvc, dcmtlish or rcpair any <br />structurc. lrior to its rssuamc, also rcquircs the applicant lor such lErmit lo filc a siSncd slatcmnl that hc or she is liccn*d PuNatrt <br />lo thc pruvisions of thc Contractor's Liccn$d Law (Chaptcr 9, Conurcncing wilh Scction 7000 of Division J of thc Busincss and <br />P()lbssions Codc) or that hc or shc is cxcmpt thqcliom and the hasis lirr thc allcgcd cxcnlPlDo. Any violalion of Setion 703 1.5 by any <br />{pplicant lirr a pcmit suhjccts thc applicant ro a civil pcnally of not morc thm livc huntlrcd dollus (s5fi)). <br />_1. as owrcr of thc lr(rlrcrty, or my cmployccs eith watcs as lhcir solc com[rnsali{nl. will do thc work atrl tlrc stru1rc is n(}l <br />inlcnlcrl or ollcred l<r mlc (Se.7044. Busircss and Prufcssions Gxlc: 'fhc Contraclor's Liccns Law d(Es not apply b an owner of <br />thcp()IEdy wlxlhildsorifi{hrvc$tlEBrn.&lwh}d(Essuchwrrkhimscltorhcrsclforthruughhisorhcrowncmpktyccs, <br />providcd lhat such inpr)v(mnts rc ilil intcrnlcd or otlcrcd tilr s{h. ll, howcrcr, lhc huilding or im{m)vcmnl is soLl within onc yce <br />ofconrplction, thc Owrcr Builder will harc lhe hurdcn of pnrving thal hc or shc dil ftil huild or imFovc thc pn IEfly tirr thc puq[s of <br />salc). <br />_1, as owncr ol'thc pr()fE-rty, am cxclusively contracting with licenscd conlraclors to crtnstnlcl thc pnrjcct (Scc. 7(X4, Busincss <br />aml PnrL;ssion Corle: 'f hc Contractor's License Law docs not apply lo an owner of prolrcrty who huilds or improves thcrcon, <br />and whq contracts lirr such projccts with a Contractor(s) liccnscd pursuant to thc Conlractor's Liccttsc Law). <br />_l ant cxL'mpt ultrlcr B. & P.C. lirr this rcason. <br />WORKERS' COTITPENSATION <br />DECLARATION <br />I hcrcby at't'irm undcr pcnalty of pcrjury onc of thc lirlkrwing dcclarations: <br />_l havc an6 will nuintain a Ccrtificate of Conscnt to Sclt-lnsurc tor wrlrkers' comlrcnsation, as p()vidcd ftlr by Scction -]7ffi of thc <br />Latxrr Crxlc, frlr thc pcrformance ol'thc work for which the prmit ls issuetl. <br />_lhavcandwillmainlainworkcrs'conrpcnsationinsurancc,as rcquircdbyScction3T00ofthcLaborCodc,tbrthcpcfiirrmanccof <br />thc w6rk tbr which this permit is issucd. My workcrs' compcnsation insurance calricr and Jxllicy nunthcr arc: <br />Policy Number: [ixPircs: <br />_l ccrtity that in lhc Jrcrlitrmance of thc work lirr which this Jrcrnrit is issucd. I shall nol cmploy atly pcrson in any manncr <br />s6 as t6 hccome suhicct to the workers'compensation laws of Calitirrnia. and agrcc that if I should hccomc subjcct to thc <br />wgrkcrs' cgmJrcnsatign pnrvisions ol'scction -1700 of the Latxrr Ctxlc, I shall. filrthwith comply with thrsc pnlvisitlns. <br />WARNING: Failurc tg sccurc wrrkers' compcnsatioll coveragc is unlawl'ul. antl shall suhject an cnlplttyer to criminal pcnaltics and <br />civil t'incs up to 6nc huntlred thuusanrl dollars (.$100,m0), in addition to tltc cost of compcnsalion, damagcs as providctl ftrr thc <br />Scclion 1076 ol'tlrc l-atxrr Ctxlc,and I'ccs. <br />5cs uS t-,or\-Lo - \q <br />unrlcr provision ol'Chaptcr 9 (c<lrnntencing with Scction 7fin) rtl'Division .lI hcre'hy allirrn undr:r pcnalty of I itrn <br />ol' lltc Busincss antl uxl my liccnsc is in full tirrcc and cflect. <br />Liccnsc C Nuntbcr:rb 553 \5 <br />S VqLa''r?-o- tq \eSU <br />I hcrchy allirm untlcr pcnalty of pcrjury that <br />issucd (Scc. 1097, Civ. C.). <br />isa agcncy titr lhc Jrcrformancc ttt'thc wtlrk firr which this Jrrrnit is <br />[-cndcr's Namc: <br />APPLICANT DECLARATION <br />I trcrrhy all-rnr undcr pcnalty of Jrcrjury onc of thc lillltlwing rlcclaratirlns: <br />Dcnxrlit iorr Permits-Asbcstos Notil'ication Fcdcral Rcgulat ions (Titlc 40. Part6) <br />-Rcquircd <br />lrttcr of Notilicalitu <br />_l ccrlity thal t'cdcral rcgulatirurs rcgarding ashcslos renroval arc n()t applicahlc to tltis pnrjcct. <br />-I <br />I hal with allCity and Ctturrly <br />onlittaltccs and County lo cnlcr ugrn llrc <br />alxrvt: <br />Pernritee <br />Agent <br />lirr insllcct ron purlx)scs, <br />,r",. I\-2O-\9 <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bf loo r/Vent/l n s u latio n <br />Roof Sheathinq 112A4-19_*r4rdr <br />Shear Wall <br />Fr:aminq <br />lnsu lation/Energy <br />Drvwall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonrv <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif. <br />I /^I <br />FINAL / / SlLc ,Y <br />Certificate of <br />Notes, Remarks, Etc