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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcrchy allirm urk cr lEnalty of pcrjury lhd I m cxcmpt liom thc c()nlrxcto6' L'rccns Law ti,t lhc tbllowing rcasrn (Scc.703 1.5 <br />Busincss anl Profcssion Crxlc): Any City or G)unty which rcquircs a Jrcrmil lo cotrslruct. alls. improve. dcmolish (tr rcpair any <br />structurc. prbr k, ils issuaree, also rcquircs thc applicanl tirr such Jrcmit k) lilc a signcd slatcrcnt that hc or shc is lien$d pusuant <br />to thc pfi,visi(|ns of tlE Conlract()r's Liccnrcd law (Chaptcr 9. Commcncing with Scction 7000 of Divisbn .] of thc Busincss and <br />PnrlbssionsGrdc)orthathcorshcisexemptthercliomandthchasisttrrtheallcgcdcxcmption. Anyviolati(rnofScctionT03l.5hyany <br />applic.nt for a lrcmit subjccts lhe applicant kt a civil pcn.lty of n(rl morc than fivc hundrcd dollils ($50O). <br />_1, as owncr ol'the propcrty, or my cmployecs with wagcs as thcir solc conrlrcnsation, will do thc wtrk and thc stn]cture is not <br />intendcd or ollbrcd lbr salc (Sec.7044. Business and Prol'csskrns Crxle: 'l'hc Contractor's [-icensc Law drrcs n()t apply to an owncr ol' <br />thc prupcrty wkl builds or impn)ves thcrqrn, arxl wlxr dtrcs such work himsclf or hcrsclf or thK)ugh his or hcr own cmployccs, <br />pr()vidcd that such impntvcrncnts arc n()t intcnJcd or ollbrcd tirr salc. lt, howcver, ltrc huilding or improvcment is sold withm onc year <br />of comphtion, tlrc Owner BuiHer will have thc burdcn ol'proving lhat hc or she dirl not buikl or improve thc pnlJrcrly lbr tlrc purJxrsc of <br />salc). <br />_1, as owncr of thc proprty, am cxclusivcly contracting with licenscd contraclors to construct thc projcct (Scc. 7044, Busincss <br />arxl Pnttbsskln Codc: 'fhe Contractor's Licensc Law rlocs not apply to an owncr of pnlJrcrty who builds or improvcs thcretln, <br />and who contracts for such pnrjects with a Contractor(s) licclrscd pursuanl trt lhc Contractor's Licensc Law). <br />_l anr cxcmpt undcr B. & P.C. lirr this rcason. <br />Dete: <br />}VORKERS' COt\ I PENSATION <br />DECLARATION <br />I hcrcby al'l'irm unrlcr Jrcnalty of prjury onc of the firllowing dcclarati<tns: <br />_l have anrl will maintain a Certilicatc of Conscrrt to Scll'-lnsurc tirr workers' comJrcnsation, as providcd lbr by Scctitln .]700 of thc <br />l-abor Culc, lbr the pcrtormance of lhc work fbr which thc Jrcrmit is issucd. <br />_l havc anrl will nraintain workcrs' compcnsalion insurancc. as rcrquircd hy Scct ion .1700 of the Labor Codc, lirr thc pcrlirnruncc of <br />thc wrrk lilr which this perrnit is issucd. My workcrs' com[rcnsation insurancc carricr arxl Jxllicy number :uc: <br />Policy Numbcr: Expircs: <br />_l ccrtity that in thc lrcrfrlrmancc o[ thc work tbr which this Jrermit is issucd, I shall not employ any [rcrson in any manncr <br />so as to bccomc subjcct to the workcrs'compensation laws of Calitbrnia, and agrce that if I should bccomc suhjcct to thc <br />workcrs' compcnsalion pruvisions of Section 1700 of thc Lalxrr Crxlc, I shall, tbrthwilh comply with thosc provisions. <br />WARNING: Failurc to sccure workcrs' compcnsation covcragc is unlawful, and shall suhject an empklycr to criminal Jrcnalties and <br />civil lincs up to onc hundrcd thousand dollars ($/r0.U[), in addition to thc cosl of compensation, damages as provided tbr the <br />Scction 3076 of lhc t-abor Codc, intcrcst and attorrr1's hel'")-,,Vitrn - <br />",,.|W*w <br />NQ't <br />,,/', \r DECLARATTON <br />I hereby atl'irm under pcnalty of pcrjury that I am licenscd under pnrvision of Chaptcr 9 lcommencing with Scctitrn 7m0) of Division 3 <br />ol' the Business and Prolbssions Codc, uxl my liccnse is in t'ull tbrcc and cttcct. <br />Liccnsc c( 0 Nunrhcr:to 33ut: <br />I 7 I <br />I hcrcby allirm undcr lrcnahy of pcrjury thd thcrc Lr a construction bnding agercy lirr thc pcrfomncc of the work for which this Frmit ir <br />issucd (Scc. 3097, Civ. C.). <br />I-cndcr's Nanrc: <br />lrnder's Addrcss: <br />APPLICANT DECLARATION <br />I lrcrrtry all-rm undcr pnalty of Jrcrjury onc of thc following dcclarations: <br />Denxrlition Pcrmits-Ashcslos Notit'ication Fedcral Regulations (Titlc 40, Part6) <br />_Rcquircd lrttcr of Notification <br />_l ccrtil'y that the l'cdcral rcgulations rcgarding ashcslos removalarc not applicable to this projcct. <br />t hal rcad this application anl statc lhal thc atxlvc inlirrnration is corrcct. I agrc'e lo comply with all City and County <br />and County to cnlcr uJxtn tlrc[.aws rclating to building construction, and hcrchy aulhorizc rcprcscnlalives of this City <br />profrcrly lilr insJrcction <br />I <br />Agent <br />atxrve <br />n:tnlc <br />0!rlx)ses, <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenVl nsu lation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsu lation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif . <br />tl <br />FINAL /L/ /)/r 0 %, 1/t.Y <br />Certificdte of O6cupancy <br />Notes, Remarks, Etc. <br />hk lr?-l/lq