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BUILDING- INSPECTOR RECORD <br />,! <br />SITE.WORK DATE ID/SIG.COMMENTS <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf Ioor/Ve nt/l nsu latio n <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Enerqv <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />I\/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Enqineer Final Report , <br />Flood Zone Certif <br />I I <br />FINAL l(,r1 ,?rt r*kv" <br />Certificate of Occupancv It <br />Notes, Remarks, Etc. <br />\ <br />./ <br />\ <br />I hereby affirnt under penalty of perjury that I irm exenrpt fronr the Contractos' License l;rw for the following reason (Sec.7031.5 <br />llusincss and Prol'ession Code): Any City or County which rcquires a Jrcrrnit to construct, alter. irnprovc. dcrnolish or rcpair any <br />stnrclure. prkrr to its issuance. also requires the applicarrt firr such pernrit to file a sigrrd slatetnent that lr rlr she is liccnsed pursuant <br />to thc' provisions of thc' Contractor's l,iccnsed law (Chaptcr 9. Cornrncncing with .Section 7(XX) ol' Division 3 ot'the llusincss and <br />Prot'essionsCode)orthatheorsheisexempltherettonrarrdtlreba.sisltrrtlrcallegedexenrption. AnyviolationofSectionT03l.5byany <br />appliclrrt for a perrnit subjects thc applicant to il civilperraltyoInot more tharr llve hurrdred dollars ($5Otl1. <br />_1. as owncr ol'thc propcny, or rny crnployces with wages as thcir solc cornpcnsalion, will do the work and thc stnrcture is not <br />intentled or oflbred for sale (Sec.7(Xa. Business and Professions C<xlc: Tlrc Conlraclor's License Lnw does not apply lo an owner of <br />the pmp€fly who bttilds or improves thereon" auxl wlro does such work hinrself or lrerself or lhrough his or her own employees, <br />provided that such irnprovcrrcnts arc rnt intcnded or ollcred l'or salc. ll. howevcr. tho building or improvcrnent is sold wilhin one )ur <br />of conqrletkrn, ttrc Owrpr Buikler will lurvc the burden of provirrg tlurt lrc or she tlid not build or impnrve the propaty for tlre purgr:;e of <br />sale). <br />-1, <br />as owner of the propcrty, am exclusively contracting with liccnsetl conlraclors to conslruct the pnrject (Sec. 7(X4, Business <br />arxl holessi<rn Code: The Contractor's Liceuse Law does not apply to an owner of property who builds or improves lhere<ln. <br />ancl who conlracts for such projccts wilh a Contractor(s) licensctl pursuant to thc Contractor's License Law). <br />_l anrexempt under Section_. B. & P.C. lbr this reason. <br />-l <br />have anl will nuintafur a Certilicate of Consent to Self-lnsurc frrr workers' comlrrrsation, as provided for by Section 3700 of the <br />l.atxrr Codc, for thc Jrcrformance of the work lbr which thc pcrmit is issued. <br />_I Irave rrttrl 3700 of the krbor Code,lirr tlre Jrcrformance of <br />t lrc wrlrk tirr arxl ;xrlicy rtunrtrcr <br />poticy*u,',n.," laBlzt8 rixpires:9'I 'tt <br />_l ccrrity that in thc J*-rfirrrruncc o[tlrc work for which tlris pcrnrit is issucrl, I shall not cnlpk)y any pcrson in any manncr <br />so as to hccorrc subjcct to thc workc'rs'cornpcnsation laws ol'Calil'ornia. and agrcc that if I should bccornc suhjcct to thc <br />workers' cornpensation provisions of Section 3700 of the Labor Cule, I sturll, forthwith conrply with tlmse provisions. <br />WARNING: Failurc to sccurc workcrs' conrpcnsation covcrugc is unlawful. antl shall suhjcct an cnrpkrycr to criminal pnaltics and <br />civil fines up to onc hundred thousand dollars ($l(X),(XX);. in addition to the cost o[ conrpensation. danmges ls provided for the <br />Seclion 3076 of the l-abor Crxle, interest and atlorney's fees. <br />E,-2,o <br />I hcrcby al'linn undcr l&-nalty ol'pcrjury that I arn liccnscd (cornmencing with Scction 7ff}()) ol'l)ivi.sion 3 <br />ot' thc Busincss an<l Prolbssions Codc. iuxl nry liccnsc is in hrll lirrcc aml clfLct. <br />C:r 3rrco/J <br />tll-ro ?d, <br />I heretry athrnr under ;renalty of perjury that there is a construction lendlrg <br />issucd (Scc. 3097, Civ. C.). <br />Jrcrformarrce of the work frlr which this pernrit Ls <br />l-ender's Narne: <br />l.cnrlcl's Atldrcss: <br />APPLICA TTIT DEC I,ARATION <br />I trrcby affrm under pnalty of perjury r.rne of the followirrg declaratiorrs: <br />Denrolition Permits-Asbestos Notification Federal Regulatiorrs (Title -10, Part6) <br />_Retluired Letter of Notification <br />_[ certily that the t'ederal regulations regarding asbeslos renxrval are rx)t applicable to this pr<r.ject. <br />_l ccrtify that I have read this application and .stale that the abor,e information is correct. I agree to comply with all City and County <br />ordirrances ard State Laws relating to building lrereby aullurrize represenlalives of this City and Courtty to enter uprn tlrc <br />atxrvc rrcntioncrt propcrty lirr <br />or Agent <br />9, (z- 1^ <br />Rev. 0B-07-2015 <br />I <br />l)ate: Owner: <br />W()RKI.:RS' C( )M PI.:NSATION <br />DECI,ARATION <br />I hcreby atlirm undcr penalty of perjury onc of thc tbllowing dcclarations: <br />al'c: <br />Annlic:rnt: