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BUILDING- INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby ilffirm undcr pcnalty of pcrjury that I m cxcmpt frcm thc Contractom' Liccns kw for thc followinS rcaen (5(.7031.5 <br />Busincss and Profcssion Codc): Any Cily or County which rcquircs a Frmit lo onstrucl. allcr. improve, &mlish or rcpdir any <br />structurc. prior lo its issuancc. also rcquircs the applicet for such Jrcmil to filc a sigrcd stalcmnt thal hc or slrc is liccnscd pu6uant <br />to lhc prcvi$iors of thc Coilractor's Liccnscd [:w (Chaptcr 9, Commcrcing with Scclion 7000 of Division 3 of thc Busittcss and <br />Prefcssi<nsCodc)orthathcorsheiscxcmptthercfiomandthcbasisforthcdllcgcdcxcnution. AnyviolalionofseliotrT03l.5byany <br />applicanl for a permil subjets thc applicant to a civil pcnalty of not Norc than fivc hundrcd dollils ($500). <br />d,. o* owrcr of Ihc prcpny, or my cmplolrccs with wagcs as thcir sh conrJrcnsation, willdo thc work srd the stnEtw is ml <br />intcndcd or offcrcd for sle (Sd.7O44, Busincss ud Profcssions Codc: Thc ContEctor's Liccns ljw d@s not .pply to il owncr of <br />lhc pm]Eny who builds or imlrrcrcs thcmn. ard who des sEh mrk himsclf or hcrelf or thrcugh his or hcr own employccs. <br />providcd lhat such impmrcmnls N mt intcnfu oroffcrcd for slc. lf. howcw. lhe boibing or imprcvcnrnt is sH within orc )ae <br />ofcornphtion. thc Owncr BuilCs will harc thc budcn ofpmving that hc or shc dkl rct buiu or in{,orc Ihc prcIsly for thc puqns of <br />sh). <br />-1. <br />tr$ owncr of the pmpcny, om cxclusivcly contmcting with liccn*d conlrsctoF to construct thc pmjelt (Ss. 7O44, Busincss <br />arxl Proli:sskrn Codc: Thc Contractor's Liccnse Law docs not apply to an owncr of prcpcrty who builds or imprcvcs lhcrcon. <br />snd who @ntEcts for such prcjccts with a Contmcto(s) lhcnsd pursuant to thc Contractor's Liccnrc [aw). <br />-lantcxclnplundcrSection-'B.&P.C.forthisreason.o,r",qo8/o? /2o2 <br />DECLAITATION <br />I hcrcby affirnr under penalty of pcrjury onc of the following declarations: <br />_l havc and will maintain a Certificatc of Conscnt to Sclf-lnsurc for workers' compensation. os provided for by Scction 3700 of thc <br />Labor Codc. lbr the pcrfornrance of thc work tbr which thc pcrmit is issucd. <br />_l havc and will milintain workcrs' comlrcnsation insurancc, as requircd by Scction 3700 of thc [:bor Codc. for thc lrcrfornuncc of <br />thc work for which this permit is issued. My workers' conryrcnsation insurance calTier and plicy numhr iue: <br />ccrtily that in thc pcrtbrnrancc of thc work tbr which lhis pcrrnit is issucd, I shall not crttploy any pcrson in any manncr <br />so as to bcconrc subjcct to thc workcrs'comperrsation laws of California. and agrce that if I should bccomc subject to the <br />workcrs' compcnsation provisions of Scction 3700 of the latnr Codc. I shall, lbrthwith comply with thosc provisions. <br />WARNING: Failure to secure workcrs'compcnsation covcrdgc is unlawful. and shall subjcct an cmployer to criminal pcnaltics and <br />civil tincs up to one hundred thousand dollars ($l0o.00tl). in addition to the cost of compensation. damages as provided for the <br />Scction 3076 of the [:bor Code. interest and attorney's fccs.a <br />D,t", . 06 / o? /202/ <br />I hcrcby allirrn under penalty of pc{ury lhat I artt liccnscd 9 (cornrncrrcing with Scction 7000) of Divisionl <br />of thc Busincss and Prot'cssions Codc. and my liccnse is in t'ull forcc and clfcct. <br />License Class: Liccnsc Numbcr: <br />Date: <br />W <br />I hcrcby sfiirm undcr penalty of Frjury lhat thrc is a @nstruction hnding agcrcy for thc pcrfomurce of thc work for which this pcrmit is <br />issucd (Se. 3097, Civ. C.). <br />, <br />lrndcr's Addrcss: <br />D <br />APPLICANT DF'CLARATION <br />I hcrcby afTinn under penalty of perjury onc of thc following dcclarations: <br />Dcnrolition Pcrmits-Asbcstos Notification Fedcral Rcgulations (Titlc 40. Part6) <br />-Rcquircd <br />Lctter of Notification <br />a, <br />-l <br />ccrtily that thc fcdcrol rcgulntions rcgarding asbestos rcmvalarc nol 8pplicablc to this projccl. <br />J-l ccnify rnar I havc rcad this applicalion ald shtc that thc abovc inforrotion is coEel. I agrc to comply wiih 8ll Cily and Counly <br />r6rdinanccs and Starc tjws rchring to building construction, ard hcreby authorize rcpresntalivcs oflhis City and Coutrly to cnls uIDn thc <br />abovc rncnliortcd propcrty for inspcction <br />Applicant or Agent <br />Permitee name tp.intl, K 5t/ <br />L o,r"t r8 /c? /202 I <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenVI nsu Iation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsu Iation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />[Vlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />t n lt ^ro <br />FINAL t (, <br />-/A vhltr,/ <br />Certificate of Occupancy \l t <br />Notes, Remarks, Etc <br />-+ <br />Carricr: <br />Exoircs: