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ILDINC- INSPECTOR RECORD SITE.WORK DATE ID/SIG COMMENTS Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf Ioor/VenVl nsu lation ,l tl Roof Sheathinq ?ht/q,ffiu Shear Wall t//\) Framinq / lnsu !ation/Enerqy Drywall Ext./lnt. Lath Brown Coat I\/asonrv Pool Fence T-Bar Handicap Req. Deputy Final Report Enqineer Final Report Flood Zone Certif t/n FINAL tbl6le fLuI fi ) Certificate of Occupancv --Notes, Remarks, Etc. OWNER BUILDER DELCARATION I hcrcby affirm undcr Fnalty of pcrjury Ihal I m exempl frcm the Contreto6' Liccnsc [:w for rhc following rcasn (5@.7031.5 Busitrcss and Profcssion Codc): Any City or Counly which rcquircs a IErmit to construct. altcr, imprcvc, demlish or rcpairtny structurc, prk r to its issuance, llso rcquircs thc applicant for such IErmit to fih a signcd slalcrent th{t hc or she is liccnpd pursuant to lhc pmvisions of thc Contractor's Lien$d Lrw (Chaplcr 9. Comrcncing sith S6tion 700O of Division 3 of thc Busircss and PrcfcssionsCodc)orthathcorshciscxemptthsefromandthebasisforthcallcgedcxcmption. AnyviolalionofsGlionT03l.5byany applicant for a lrcrmit $ubjsts thc applicant to a civil pcnalty of not mrc than five hundrcd dollars ($500). _1. as owncr of thc propcrty. or my cmployccs with wages as thcir sole compcnsation. willdo thc work and thc stnrcturc Ls not intcnded oroft'crcd for salc (Sec.7044, Busincss and Profcssions Codc: The Contractor's Licensc [,aw docs not apply lo an owncr of thc propcrty who builds or inrprovcs thcreon. and who docs such work himsclf or hcrsclf or through his or hcr own employccs. providcd that such improvenrnts arc not intcrxlcd or offcrcd for salc. If, however. thc building or improvcnrent is sold within one year of complction. thc Owncr Builder will have thc burden of proving that hc or shc did not build or improve the proprty for the purposc of salc). _1. as owncr of the prolrcrty, am cxclusivcly contracting with liccnsed contractors to construct thc projcct (Sec. 7U4, Business and Proficssion Code: Thc Contractor's Licensc Law does not apply lo an owner of propcrty who builds or improvcs thercon, and who conlracts for such projccts with a Contractor(s) liccnsed pursuant to thc Contractor's Liccnsc taw). -l am cxempt undcr Scction- . B. & P.C. for this rcason. Datc: }YORKERS' C( TNI PENSATION DECLAITATION I hcrcby atfirm under pcnalty of pcrjury onc of thc following declarations: _l havc and will rnaintain a Certificatc of Consent to Sclf-lnsurc for workcrs' compcnsation. as providcd for by Section 37fi) of the Latxrr Code. tbr thc perforrrrance of thc work fbr which thc pcrmit is issucd. _l havc and will Scction 3700 of thc Lrbor Codc. for thc lrcrformancc of thc work for carrier and policy ttunrbcr arc: - Policy ZS -l ccrtify that in thc pcrformancc of thc work for which this pcrmit is issucd. I shall not employ any lrcrson in any manncr 7 so as to bccorne subjcct to the workcrs'compcnsation laws of California, and agrce that if I should becomc subjcct to thc workers' compcnsation provisions of Section 3700 of the L:bor Codc. I shall. forthwith comply with thosc provisions. WARNING: Failure to sccure workcrs'comlrcnsation covcragc is shall cmploycr to criminal pcnaltics and civil fincs to one hundrcd thousartd dollars ($100.000), in darnagcs as nrovidcd for thetuScctionintcrcst and fccs.Z/ I hercby affirnr undcr pcnalty of pcrjury that I am liccnrcd under provision 9 (cornnrcncing with Scction 70m) of Division 3 of thc Busincss and Prol'cssions Codc, and nty licensc is in full fbrcc and clfcct. a so 5&z I hcrcby aftirm undcr pcnalty of prjury that thcre is a construction hnding issucd (Scc. 3097. Civ. C.). for lhc lrcrformancc of thc work for which this pcrrnit is L,cndcr's Narnc: [.cndcr's Addrcss: APPLICANT DECLARATION I trcrcbyaffinnunder pcnalty of perjury onc of thc following dcclarations: Dcmolition Pcrrnits-Asbcstos Notification Fcdcral Regulations (Titlc 40, Part6) -Rcquired lrttcr of Notification _l ccrtify that the l'cdcralregulations rcgarding asbcstos rcmovalarc not applicablc to this projccl. t _l ccrtify that I have rcad this application is corrccl. I agrcc to comply with all City and County <lrdinanccs and Statc Laws rclating to reprcscnlativcs of this City and abovc lncntioncd propcrty lbr Applicant or Agent Pernritee nanle d to entcr upon the _ Owner: ZJ Liccnsccrass: C-37 lil"nr" Dale: " \ /