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BUILDING- INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG COMMENTS OTVNER BUILDER DELCARATIoN <br />I hcrcby illlirm undcr Fnahy of Frjury thlt I am cxcmpt lhlm thc ContrackrB l-iccns [jw tirr lhc following rcason (Se.70-11.5 <br />Busirrcss aul Prolbssiur C(xle): Any City or Coutrty which rcquircs a [Ernlit to construcl. rller. improvc. dcmolish (rr rcpair anl <br />slnrclure. prior kr its issuarec. also rcquircs lhc applicanl lirr such Frmit lo lih a signcd stalcmnt lhat hc (tr shc is liccnscd fursuanl <br />kr lhc pR)visbns of thc Cultrackrr's l.iccnrcd Law (Chrylcr 9, Conrmcncitrg wilh Scction 7m0 ot Divisi(xl J of thc Busincss and <br />Pnrlcssions Codc) or that hc or shc is cxempl thcrcliom ed thc basis li)r lhc allc8cd crcmptirlr. Any virlatiolr ol Sccti()n 7011.5 by any <br />applicaotlirrapcmitsubjcclsthc applicantk)acivilpcnaltyofnolmorcthanfivchundrcddollrs(S5U)). <br />_l. as ()wncr ot the pn)pcrty. or nly cmployces wilh wagcs as lheir s()lc conrpcnsaliort. will do tlrc work arxl thc slrur"*turc is not <br />lntcnded ()r ofi'crcd lirr salc (Scc.7044. Busincss and Pnlfcssions Crxlc: '[hc Conlractor's l.icensc l-aw drrcs nol apply to an owncr of <br />lhc ;rnrpcrty who huiltls or inrprovcs tlrcrcon, and wlxr drrcs such work himsclf or hcrscll'rlr through his or lrcr own employccs. <br />providcd lhat such inrpnrvcnrnts arc not intcrxlcd or otlbrcrl lirr sirlc. Il. howcvcr. tlrc buik-ling or inrprovcnrnl is sokJ within one year <br />ol'complction, lhc ()wner Buildcr will havc thc burrlcn of pnrving lh:rt hc or shc tlitl not huild or intprovc the pnr;rcrly lbr lhc puryxrsc rtt' <br />salc). <br />_1, asowncrof'lhc pnlpcrly, amcxclusivclyconlracling with liccnsctl contritclorslocottstrucl lhc pnrjct:t (Scc. 7044, Rusincss <br />anri PrulbssionCodc: 'l'hcContraclor'sl-icenscLawdocsnotapplytoanowncrot'proJrcrtywhohuildsorintprovesthcrcon, <br />atrtl who conlracls lor such pnrjccls with a Contractor(s) liccnscd pursu&nl ltl thc (bnlractor's l-icettsc Law). <br />-Iamexc-ntptulldcrSectirlrt-.B.&P.C.tilrthisrcasrln.Orvner: <br />}VORKERS' CON IPENSATION <br />DECLARATION <br />I hcrcby al'l'irrn undcr pcnalty of pcrjury one ol'thc folkrwing rlcclarations: <br />_l havc and will maintain a Ccrliticatc of Conscnt to Sclt-lnsure frrr workers' comJrcnsatir)n. as pr)vidcd for hy Scction -]7U) of the <br />Lahrlr Codc, lilr thc- pcrfbrmance ul'thc work firr which the pcrmit is issuerl. <br />UAI haue,r,.l .17(X) ol'thc Labor (idc. lirr thc pcrlirnnaltcc ot' <br />llrc work lix'iurtl lxllicy nunrhcr arc: <br />r <br />Policy Nu .{7 )-o <br />_l ccrlity llrat in thc pcrlirrnrance ol'lhc work lirr whiclr tlris Jrcrnrit is issuctl. I shall rxrt crnploy any pr'rson irr arty rllann(.r <br />so aslotrcconrcsuhjccttollrcworkcrs'cornlrcnsalionlawsol'Califtlrnia.anditsteethitlil'lshtttrldbccomcsuhjccllolhc <br />workcrs' cornpcnsalion pnrvisions ot'Scctiorr J700 ot'llrc [-:alxrr Crxlc, I shall, lirrthwillr comply witlt tlxrsc provisions. <br />WARNIN(i: l;ailurc' lo securc wrtrkcrs' contlrcnsalion covcrilrc <br />civil lincs up to orrc lrundrr-'tl tlxrusand dollars ($l(U.fiX)). irr <br />is unlawful.subi'cl an to crinrinal pnaltrcs and <br />additiorr ol providetl tilr the <br />Scclion.107(r I ltt'inlr'rcst altd attrlrtrcy' s l'ccs. <br />I hcrchy al'l'irnr undcr pnalty ol'prjury tlrat I ant lic:crtscd undcr of C'haptcr 9 lconrnrcncing with Scction 7UX)) of Division J <br />ol' thc Busincss antl Prol'cssions Cotlc. arl nry liccnsc is in lirll lirrcc and clll'ct. <br />Liccnse <br />( <br />W <br />I hcrcby afl-rm uftlcr Fnalty of lrcrjury thal lhsc is a rarnslructhn lcnding agcncy for thc Jrcrlormucc of thc work br which this tEmit is <br />issucd (Scc. -1097, Civ. C.). <br />hnrlcr's Namc: <br />[.cndcr's Adtlress: <br />APPLICTANT DECLAR,\TION <br />I lrcr-*hy allirrrr undcr pcnalty ol' pcrjury onc of thc folkrwing dcclaral ions: <br />f)crnolition Pcrmits-Asbcslos Notil'ication I'cdcral Rc'gulations (f itlc 40. Part6) <br />-Requ <br />u'ctl Lcttcr of Nolilicatnlrr <br />with all City and County <br />_l ccrtily lhat thc t'cdcral rcgulations regarding astrcstos rcnxrvalilrc not lo this pro.icct. <br />anrl <br />7 <br />Io cnlcr u;xxr thc <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenVI nsu Iati o n <br />Roof Sheathing <br />Shear Wall <br />Framing <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />lt/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif . <br />1/n <br />I <br />FINAL arD 5-ful 7 x lu,l[ <br />Certificate of Occu <br />Notes, Remarks, Etc.