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BUILDING- INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS olvN l.lR Ilt,tLl )ER I)Fll.CARA'l'l()N <br />I hcrcby allirm undcr pcnalty of frcrjury that I am cxcmpt ltom thc Coilrrck)rs' Licctrsc Law for lhc l()llowirg rca$n (Scc,70-11.5 <br />Business and Protcssion Gxtc): Any City or Grunty which rcquircs a frcmit k) consIruct. altcr. improve. &molish or rcpair any I <br />structurc. prior lo its issuancc, also rcquircs thc applicanl for such Fmit k) filc a signcd stdcmnt lhal hc or shc is liccnsd pursuanl. <br />k) thc pnrvisiols of thc Contractor's Liccnrcrl hw (Chaptcr 9, Commcncing wilh Scclion 7000 of Division J o[ lhc Business and <br />Pnrtbssions Clorlc) or lhat hc or shc is cxcmpt thsclirnn and thc b{sis tor lhc dlhScd cxcmpli(nl. Any violuli(ln of Setion 703 | .5 by any <br />applicant for a pcrmil suhjftts lhc applicanl to . civil pcnally ()f nol morc than tivc hundrcd dolles ($50U). <br />_1, as owncr of thc pK)pcrty. or my cmphyees with wagcs as thcir sole comlrcnsation, will do thc work atxl lhc struclurc is not <br />intentled or oll'crcd lirr sale (Scc.7M4, Business and Prot'essions Codc: 'Ihc Contractor's Liccnse Law docs not apply to an ttwncr ol' <br />thc pnlJrcrty who builds ()r improvcs tlrcreon, arxl who tftrcs such wrlrk himsclf or hcrsclf or thrrtugh his or hcr own cmployccs, <br />providcd that such impntvcnrents are not intcrxlcd or otlbrcd fbr salc. lt. howevcr. thc huiklirtg or impnrvcrnenl is sokl within onc ycar <br />gf comphtkrn. thc Owncr Buikler will havc the burdcn of proving that hc or slrc did not buikl or improve thc pnrJrrty for thc purprsc of <br />salc). <br />_1, as owncr of the proprty, anr cxclusivcly contracting with liccnscd contraclors l() c()nstntct the prljcct (Scc. 7044. Busincss <br />and Prufcsskrn Codc: 'l'hc Contractor's Liccnsc Law does not apply to an owner of proJrcrty whtl builds or improvcs thcrcon, <br />and who contracts tilr such projccts with a Contractor(s) liccnscd pursuanl lo thc Contractrlr's Liccnsc law). <br />_l anr cxcntpt undcr Scction-, B. & P.C. tilr this rcason. <br />IVORKERS' CONI PENSATION <br />DECLARATION <br />I hcrchy al'l'irnr undcr pnalty of perjury onc of thc lirllowing dcclarations: <br />_l havc all will nraintain a Certitlcatc of Conscnt to Sclf-lnsurc lirr workcrs' compensali()n. as pnrvidcd ttlr by Scctirln 3700 of thc <br />Lalxrr Ctxlc, lilr the pcrlirrmancc of lhc work frrr which thc Jrcrmit ls issucd. <br />-l <br />havc and will maintain workcrs' cttmlrcnsatirllt insurancc. as hy Scction .]7fi) ol'the Lahor CorJc, fbr thc lrcrtirrmance of <br />carricr arxl grlicy numhcr arc:thc work lirr which this prmit is issuctl. My <br />- 5|q UIA <br />\L-\-)q(a qq oL OPolicy <br />_l certily thal in the lrcrlilrmancc ol'thc work lor which this Jrcrnrit is issucd, I shall not cntpkly any pcrson in any manner <br />so as to bccomc subjcct to thc workcrs' compensation taws of Calilirrnia, and agrcc that if l shttuld bcctlnrc subjcct to thc <br />workers' conrpcnsation provisions ol'scction J7(X)ol'thc Latxrr Crxlc. I shall. lirrthwith comply with those provisions. <br />1VARNING: Failurc to sccure workcrs' compcnsatiotr covcragc is unlawful. and shall suhjcct an cmpkrycr to criminal Jrcnaltics and <br />civil lrncs up to onc huntlrctt thousand rlollars ($100.UX)), in atldition to lhc cost of crlmJrcnsatitln, damagcs as provirlcd lirr thc <br />Scction 1076 ol'the Lahtr Ctile, intcrcst altd atltlrncy's l'ecs.,lb,,",.,, lt- IB-'\1 rl <br />I hcrcby al'l'irnr undcr pcnalty of pcrjury that I am licclrsctl pnrvision ol'Chaptcr 9 (contntcncing with Scclitln 7UX))ol'Divisirl, 3 <br />| <br />ot' ttrc Busincss and Prol'cssions Codc. and my liccnsc is in lirll lirrcc and cll'ccl. <br />l-iccnsc <br />-c_z\ <br />Numhcr: <br />,q5 '{3 <br />CONSTRUCTION LENDING AGENCY <br />I hcrchy allif[ under FnallyotFrjury thd thcrc is d constructir lcrding aScncy li]r thc Frli,rmncc of lhc w(]rk tbr which this lEmit is <br />issucd (Scc. -1097, Civ. C.). <br />[-ender's Address: <br />APPLICANT DECLARATION <br />I lrcrcby all-rm under pcnalty of ;rcrjury tlnc of lhc lbllowing r-lcclaratitlns: <br />Dcm6litiorr Pcrmits-Ashcstos Notification Federal Rcgulations ('Iitlc 40, Part6) <br />-Rctluirctl <br />Lrtter ol' Notilicatkrn <br />_l ccrtily lhat thc l'cdcralrcgulations rcgarding ashcslos rcnxlvalarc not applicahlc to this llrojcct. <br />Y)/rcertily that I havc rcad this applical <br />rlrrlinanccs and Statc Laws rclating lo hui <br />abovc mcntioncd prolrcrty lilr furspcctittn <br />ion and state that the ahlvc inlirrmation is corrcct. I agrce to c<lmply with all City and County <br />of this City and County lo cnter uJxrn tlrc <br />Applicant or Agent <br />Wanlt 'l UEIrenrtitee nAnlc <br />ilding construction, and hcrchy auttxrrizc reprcsentalives <br />,l )-tB-lqLlate: ' <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bf loor/Ve nVl ns u latio n <br />Roof Sheathinq fi- /8- lg IBr?,/d9 <br />Shear Wall <br />Framing <br />lnsulation/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 />Enoineer Final Report <br />Flood Zone Certif . <br />FINAL )l-t4-l I rY--4/*, <br />Certificate of Occupancy <br />Notes. Remarks, Etc. <br />.4