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BUILDING- INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby affirm undcr pcmhy of Frjury that I m cxcmpt frcm thc Contractos' Liccns law for thc following rcasn (Scc.703l.S <br />Busincss and Prcfcssion Codc): Any City or County which rcquircs a ;rcmit to construct. altcr. improve. demlish or rcpair any <br />structurc. Jrior Io its issuancc. also rcquircs the applicant for such prmir to filc a signed statcmnl that hc or shc is liensd pursu.nt <br />to thc pmvisions of the Contractor's Liccnred kw (Chaptcr 9. Commercing with S$tion 7fiD of Division 3 of thc Business and <br />PrcfcssionsCodc)orthathcorshciscxcmptthcrcfromondthcbasisforthcallcgedcxemption, AnyviolationofSetionT03l.5byony <br />applicant for a Jrrmit subjccts thc opplicant to a civil pcnalty of not mrc than fivc hundred dollus ($500), <br />_1. as owncr of thc propcrty, or my ctnployces with wagcs as thcir solc conlpensation. will do thc work and thc structurc is not <br />intcndcd or ofl'crcd tbr salc (Scr.7044. Busincss and hofessions Codc: Thc Contractor's l-icensc [^aw does not apply lo an owncr of <br />thc propcrty who builds or itnprcvcs thcrcon, and who dcrcs such work hinrsclf or hcrsclf or lhrough his or her own enlployccs. <br />providcd that such improvcnrcnts arc not intcndcd or oft'crcd for salc. lf. however. thc building or improvcnrcnt is sold wilhin onc ycar <br />of conphtion. ttrc Owncr Builder will have thc burdcn of proving that hc or she did not build or irnprovc thc property for thc puryn$ of <br />sillc). <br />_1. as owncr of thc propcrty, atn cxclusivcly contracting with liccnscd contractors to construcl thc projccl (Sec. 7M4, Busincss <br />ard Prolbssion Codc: Thc Contruclor's Liccnsc Law docs not apply lo an owncr of propcrty whcl builds or improvcs thcrcon, <br />atrd who contracls for such projccts with a Contractor(s) liccnscd pursuant lo the Contractor's Liccnsc [aw). <br />-l <br />um cxcrnpt undcr Scction-. B. & P.C.this rcason. <br />Date:__b'lb'Ll <br />I hcrcby alllrrn undcr pcnalty of pcrjury one of thc following dcclaralklns: <br />_l havc and will lnaintain a Ccrtificatc of Conscnt to Sclf-lnsurc tbr workcrs'contpcnsation. as providcd for bySection 3700 of thc <br />l,irtxrr Codc, for thc perfornrancc of thc work for which thc pcrmit is issucd. <br />_l havc and will maintain workcrs'compcnsation insurancc. as requircd bySection3T00of thc LaborCodc. forlhcpcrfornurnccof <br />thc work for which this grcrmit is issucd. My workcrs' cornpensation insurance carrier and gllicy number are: <br />Policy Evnirn.. <br />_l ccrtify that in thc performancc of thc work tbr which this pcrrrrit is issued, I shall not cmploy any pcrson in any manncr <br />so as to bccome subjcct to thc workcrs' cornpcnsation laws of California. and agrce that if I should hcconrc subject to the <br />workers' compcnsation provisions of Scction 3700 of thc l-^atnr Code. I shall. forthwith comply with those provisions. <br />WARNING: Failurc to sccurc workcrs' compcnsation covcragc is unlawful. and shall subjcct an employer to criminal pcnaltics and <br />civil fincs up to one hundrcd thousand dollars ($100,000), in addition to lhc cost of conqrcnsation. damagcs as providcd for the <br />Scclion 3076 of thc [:bor Codc. intcrcst and attorney's fccs. <br />-- <br />DECI ARATION <br />I hcrcby at'llrrn undcr penalty of pcrjury lhal I am liccnscd undcr provisiott of 9 (conrmcncing with Scction 7m0) ol'Division 3 <br />of thc Busincss and Profcssions Code. and my liccnse is in full force and cffcct. <br />Liccnse Class: License Numbcr: <br />I )utr::Contractor:_ <br />CONS'I'RI.IC'I'I0N I,I.]N I)IN( ; A(; IiNCY <br />I lrcrcby aflirm udcr Fnalty of Frjury that thcrc is a construction lcnding agency for lhc lrcrtbrmncc of thc work for which l,iit lrcrmil is <br />issucd (Scc. 3097. Civ. C.). <br />Lcudcr's Naurc: <br />[rndcr's Addrcss:.a <br />3 <br />APPLICANT DFCI ARATION <br />I hcrcby affinn undcr pcnalty of pcrjury onc of thc following dcclarations: <br />Dcrnolition Pcrmits-Asbestos Notiticalion Fcdcral Regulations (Titlc 40. Part6) <br />-Rcquircd <br />lrttcr of Notification <br />_l ccrtify that the fcdcral regulations rcgarding asbcslos rcmoval iuc not applicable to this projcct. <br />_l ccrtily that I have rcad this application and state that thc akrvc inforrnation is corrcct. I agrcr to cornply <br />ordinanccs and Statc [:ws rclating to building construction. and hcrcby authorizc rcprcsentatives of this City <br />I <br />abovc nrcntioncd property for <br />with all City and County <br />and County to cnter uJxln thc <br />e-l$ -ilApplicant or Agenl <br />Ifcrnrilce nnnrc <br />Set Backs <br />Forms/Steel/Holdowns !x7 at DnatdFr Per\ro W\rY( <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf Ioor/Ve nVl nsu I ati o n t <br />Roof Sheathinq I )Ll lrt <br />Shear Wall I ,/ <br />Framinq r <br />17 I tV ,lLt l>{4w I <br />lnsulatio nlEnerqy -, <br />Drvwall <br />Ext./lnt. Lath <br />Brown Coat <br />I\/asonrv <br />Poo! Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />tl D- <br />FINAL /17 ?(utw 5v/ <br />Certificate of Occupancy <br />Noteg, Rpmarks, Etc.I <br />rl II <br />t <br />,