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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby affrm undcr penalty of pcrjury that I en cxcmpr frcm thc Contracto6' Liccn$ Law for lhc following rcasn (Sc.7031.5 <br />Busitrcss and Profcssion Codc): Any City or County whhh rcquircs ! Frmit to @nstruct, altcr, imprcvc, demlish or rcpair ily <br />struclurc. prior to its issuarce, also rcquircs thc applicanl for such lrcmil to lilc a sigrcd slatercnt that hc or she ir liccnscd pusuanl <br />to thc provisions of tlE Contractor's Liccnscd law (Chapter 9, Comncing with Setion 7000 of Division 3 of thc Busincss ud <br />PnfcssionsCode)orthathcorshciscxcmptthcrcfromandlhcbasisforthcallcgcdcxcmption, Anyviolalionofs@tion703l.5byany <br />applicant for a prmit subjccts thc applicant to a civil pcnalty of not mre than live hundred dollus (3500). <br />-1. <br />as owncr of thc propcrty. or my cmployccs with wagcs as thcir sole cotnfrensation. willdo thc work and thc stnrc{grc is not <br />intcndcd or otTcred for sale (Scc.704f, Busincss and Profcssions Codc: The Conlractor's Liccnse law docs not apply to an owncr of <br />thc propcrty who builds or improvcs thcrcon. and who docs such work himsclf or hcrsclf or through his or hcr own crnployccs. <br />providcd that such improvcnrcnts are not intended or offercd for salc. If, howcvcr, thc building or improvctrnnt is sold wilhin onc )car <br />of cornplction. the Owncr Buildcr will have the burdcn of proving that hc or she did not build or improvc the proprry for tlrb purpsc of <br />salc). t <br />-1. <br />as owncr of thc propcrty, arn exclusivcly contracting with liccnscd conlraclors to construct the projcct (Sec. 7W, Busincss <br />ancl hofession Code: The Contractor's License Law docs not apply to an owncr of propcrty who builds or improves thcrcon, <br />and who contracts for such projects with a Contracto(s) liccnscd pursuant to thc Contractor's Licensc [,rlw). <br />-IamcxcnrptunderScction-'B.&P.C.tbrthisreason. <br />0wner: <br />WORKERS' COMPENSATION <br />DF'CLARATION <br />I hcrcby affirm undcr penalty of pcrjury onc of thc following dcclarations: <br />-lhaveandwill <br />maintainaCcrtificateofConsenttoSclf-hrsureltrrworkcrs'conrpensation.as providcdforbyScction3T00ofthe <br />Labor Codc. ltrr thc lrcrformancc of the work lbr which thc pcrnrit is issucd. <br />-l <br />have and will maintain workcrs' comFrcnsation insurancc. as required by Scction 3700 of thc Labor Codc, tbr thc lrcrformancc of <br />thc work for which this pcrmit is issucd. My workers' compcnsation insurance carrier and Jxllicy nunrbcr arc: <br />t <br />.? <br />-l <br />ccrtify that in thc pcrformancc of thc work for which lhis pcrrnit is issucd. I shall not employ any lrcrson in any manncr <br />so as to bccorrrc subject to thc workcrs'compensation laws of California. and agrce lhat if I should bccorne subjcct to thc <br />workcrs' cornpcnsation provisions of Section 3700 of thc [:bor Code. I shall. forthwith conrply with thosc provisions. <br />WARNING: Failurc to liccure workcrs'cornpcnsation covcragc is unlawful, and shall subjcct an empklyer to criminal lrcnalties and <br />civil lincs up to onc hundrcd thousand dollars ($100.000). in thc cost of com;rensation. danugcs as providcd for thc <br />Scction 3076 of thc Latxrr intcresl and fees. <br />I hcrcby aftirrn undcr pcnalty of prjury liccnscrd provision of Chaptcr 9 (conrmcncing with Scclion 70m) of Division 3 <br />of the Business and Profcssions Codc,my liccnsc is in full forcc and cffcct. <br />Liccrtsc <br />g <br />Numbcr:'z?7 6t? <br />W <br />I hcrcby aflirm undcr pcnalty of frcrjury that th@ is I @nstruction hnding agcncy for thc pcrfotmre of the work for which Ihls frcmil is <br />issucd (Scc. 3097, Civ. C.). <br />kndcr's Namc: <br />lrndcr's Addrcss: <br />APPLICANT DF'CLARATION <br />I hercby affimr under penalty of pcrjury one of thc following declarations: <br />Demolition Pcrmits-Asbcstos Notification Fcdcral Rcgulations (Title 40. Part6) <br />_Rc<lu ircd l,cttcr of Not ification <br />-l <br />ccrtify thut the f'ederal rcgulations regarding asbcstos rcnmvalarc not applicablc to thi.s projcct. <br />--l <br />cdaify that I havc rcad this application ard statc atnvc infornration is corrcct. I agrce to comply with all City and County <br />ordinances and Statc laws rclating to building and hereby authorizc rcprcsentativcs of this City and Counly to enter upon thc <br />abovc mcntioned propcrty for <br />Applicant or Agent <br />I)ennitee nanre <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenUl nsu lation I ,l .l I Z <br />Roof Sheathinq 0 Z7 ,LI DHU.Z ;/ <br />Shear Wall <br />Framinq <br />lnsulatio nlEnerqy <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 />Enqineer Final Report <br />Flood Zone Certif <br />ll IA 1- <br />FINAL h 0 -L I)tq'(>/ <br />Certificate of Occupancy ll I <br />Notes, Remarks, Etc. <br />Date: <br />a-., *i^-. <br />Policy *"^ Expires:L/ <br />\*,",?/7 /z/