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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bf loor/Ve nVl ns u lation Roof Sheathinq Shear Wall Framing lnsulation lEnergy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif rA FINAL 7-\3r9 ),.tfl-\A Certificate of Notes, Remarks, Etc. OWNER BUILDER DELCARATION I hcrchy allirm undcr Jrcnalty of pcrjury that I m cxcmpt ln)m thc G)ntrack)s' Liccns Llw tirr lhc tbllowing rcason (Scc,70-]1.5 Busincss ahl Protbssion Cqlc): Any City or Counly which rcquircs . JErmit to coNtrucl. altq. improvc. dcmolish or rcpair rny structu.c, pri)r lo its issuancc, also rcquircs thc alplicanl for such [Ermil k) filc a si8rcd statcrcnt lhal hc or slE ir liccnsd pursuanl lo thc prcvisiuls of thc C(rltrsctor's Licclsd kw (Chaptcr 9, Grmmcncing with Sstion 7fix) of Division .] of thc Busincss and Prulcssions c()dc) or that hc or she is crcmpt lhcrcfrom and thc hasis t('r thc allcgcd cxcmplion. Any viohlion of Setirn 70.1 1.5 by any applicant tbr a lEmit suhjccts lhc applicant to a civil pcnalty of not m)rc than livc humlred dollus (S5fi)). --1, as owncr of thc propcrty, or my cmployccs with wagcs as thcir solc comJrcnsation. will do lhc work arxl thc slructurc is nol intcnrJcd rlr oll'crcd lilr sale (Scc.7044, [Jusincss and Pnrt'cssions Codc: The Contractor's Liccnsc Law drrcs not apply lo an owncr ol' thc pn)pcrty who builtls or intprrves lhcrcon, and who tftrcs such work himsclf or hcrsclf or thruugh his rtr hcr own cmpkryccs, providcd that such impnrvcm:nts arc lxrt intcndcd or oll'crcd lirr salc. Il. howevcr. thc buikling or impnrvcnrcnt is sokl within onc ycar of complction, llrc Owncr Buildcr will havc thc hurdcn o[ pnrving that hc or shc ditl rrut build rlr impnlvc thc proJrcrty lilr thc purplsc ol' salc). _1, as owncr of thc propcrty, am cxclusivcly contracting with liccnscd contractrlrs to construct thc projcct (Scc. 7M4, Business arxl lhltbssion Crxle: 'fhc Conlractor's Liccnsc Law drrcs not apply to an owncr of proJrcrty who builds or improves thcrcon. and who contracts lirr such projccts with a Contractor(s) liccnscd pursuant to thc Contractrlr's Liccttsc Law). _l am cxcmpt undcr Scction-, B. & P I hcrchy all'irm undcr Jrcnalty ol'Jrcrjury one ol'thc tblkrwing tlcclarations: _lhavcandwillmaintainaCcrtiticatcofConscnttoSclf'-lnsurctilrworkcrs'comJrcnsation.as providcdtbrbyScction3T00ofthc l-ahlr Crx-lc. lirr thc Jrcrlilrmarrcc of thc work tilr which the pcrmit is issucd. _l havc and will maintain workcrs' comJrcnsation insurancc, as rcquircd by Scction 1700 of thc Labor Codc. lirr thc lrcrlormancc of thc work tirr which this permit is issuc'rl. My workcrs' compcnsation irisurancc carricr urd Jxllicy number arc: Policy Numhcr: Expires: _l ccrtily that in thc Jrcrlirrnuncc <l[ lhc work tilr which this Jrcrmit is issuctl, I shall rrot empkly any pcrson in any manner so as to bcconrc subjcct to the workers' comJrcnsation laws of Calitirrnia, and agrcc that if I should hccomc suhjcct to thc workcrs' comJrcnsation pnrvisions ol'Scction 3700 of thc Latxrr CrxJc. I shall, lilrthwith comply with thosc provisions. WARNING: Failurc to sccurc workcrs' comJrcnsation coveragc is unlawlul, and shall suhjcct an cmpklyer to criminal Jrcnaltics and civil lincs up to onc hundrcd thousand dollars (Sl00,U)()), in adrlition to lltc cost of com[rcnsation. damagcs as providcd lirr thc Scction -1076 of thc Lahrr Ctxlc. intcrcst and attrlrncy's t'ccs. oxn, s (7-lAl 2. o DIi( ]I,AIL\'I'I0N I hereby allrnr undcr pcnalty ol';rcrjury that I am liccnrad unrlcr provision of Chaptcr 9 (commcncing with Section 7U[) of Dit ision 3 of thc Busincss and Profcssions Codc, and my licensc is in tull tilrcc and ettcct. Liccnsc Nunrhcr: Il.rr^. W I hcrcby afftrm undcr Jrcnalty of Frjury that tlrcrc is a construction lctrdiDg agcncy for thc lrcrf(rmncc of lhc w(xk for which this;rcmit is issucd (So. 309?, Civ. C.). lxn,lcr's Namc: [rndcr's Addrcss: APPLICANT DECLARATTON I lrcrcby all-rnn undcr Jrcnalty of pcrjury onc of thc folbwing dcclarations: Dcmolition Permits-Asbestos Notification Fcdcral Rcgulations (Titlc 40, Part6) -Rct1u ired [-ct tcr of Notificat i<ln _l ccrtity that thc tbdcral rcgulati<lns rcgeuding ashcstos rcnxrvalarc not applicablc t<t this projcct. with all City and County antl County to cntcr uJxrn thc Applicant or Agent Penrrilec nanle a n9,-n7 -2n 1 q ,rr"' t /2^ la|" 7o t