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BUILDING. INSPECTOR RECORD SITE-WORK DATE ID/SIG.COMMENTS Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenVl nsu I atio n t,fr Roof Sheathinq Shear Wall / Framinq lnsulation/Enerqy Drywall Ext./lnt. Lath Brown Coat lt/asonrv Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif ,A / FINAL a Y.o/r-t Certificate of Occupancv tt) / / Notes, Remarks, Etc.l oWNER BUILDER DELCARATION I hcrcby aflrtn undcr pcnally of prjury lhal I m cxcmpt liom the Contraclon' Liccns tiw for thc following rcarcn (Ss.7031.5 Busincss and Pmfcssion Codc): Any City or County which rcquires a yrcrmit to construcl, altcr, improvc, dcmlish or rcJuir any structure, prior to its issuancc. als requircs thc applicanl for such lrmil lo filc I signcd statemnt lh8t hc or slE is licen$d puswt lo thc pmvisions of thc Conrractor's Liccn*d law (Chaptcr 9. Commcncing with Srction 7000 of Division 3 of thc Busincss und PrcfcssionsCodc)orlhathcorshcisexcmptthcrcfromondthcbasisforthcalhgcdcxcmplion. AnyviolalionofSetionTO3l.5byany npplicant for a Ircmit subjccts lhe applicant to a civil pcnalty of not nbrc thsn five hundrcd dollsrs ($500). _1. irs owncr of the propcrty, or my cmployccs with wagcs as their solc compcnsation, will do lhc w<lrk arxl thc structurc is not intcndct or olTcrcd for sale (Scc.7O14. Busincss and Prot'cssions Codc: The Conlractor's Liccnsc Law docs not apply lo an owncr of thc proprty who builds or improvcs thcrcnn, and who docs such work himsclf or hcrself or through his or hcr own cmployccs. providcd that such improvcnrcnts are not inlcndcd or offcrcd for salc. If. howcvcr. thc building or improvcnrcnt is mld within one ycar of cornphtion. thc Owncr Buildcr witl havc thc burdcn of proving that hc or shc did not build or irnprovc thc propcrty for thc puryrcsc of sale). _1, as owncr of thc propcrty, am cxclusively contracting with liccnscd contraclors to construct thc projcct (Sec. 7W. Busincss and Prolbssion Code: The Contractor's License Law docs not appty to an owncr of property who builds or improves thercon. and who contracts for such projccts with a Contractor{s) liccnscd pursuant to thc Contractor's Licensc taw). I am cxcmnt undcr Scction . B. & P.C. for this rcas<ln. 0wner:_ *u **o-ns' cot r pnrr slnox DECLARATION I hcreby affinn under penalty of perjury one of thc following declarations: _l havc and will rnaintain a Certificatc of Consent to Sclf-lnsurc for workcrs' compettsation, as providcd for by Scction 3T00 of thc Latxrr Codc, for thc lrcrformancc of thc work for which the Jrcrmit ls issued. l@nou"and will maintain workcrs' compensation insurancc, as rcquired by Section 3700 of thc t-abor thc work for which this permit is E{Ed- Myrkcrs' comFnsation insurancc carrier and policy number Code. for thc arc: pcrformance of a Policy /4 _l certify that in lhc lrcrformre of thc work for which lhis pcrmit is issucd, I shall nol cmploy sny Jrcrson in any manner m as to trom subjcct to thc workm' comFnstion laws of Californi!, and agrc thrt if I should bccom subitt to tlE I workqs' compcnsation prcvisions of Sstion 3700 of thc Lihor Code. I shall, fonhwilh omply sith thos prcvisions. I{ARNING: Failurc to scurc workcrs'compensstion covcBgc is unlawful. and shall subjsl m cmploycr lo simiml lEmllics and civil fincs up to one hundred thousand dollars ($100.000), in addition to thc cost of compcnsation. danragcs as provided for attorney's fccs. ^{ichoks DECI ARATION I hcrcby affirm undcr pcnalty of perjury that I am licenscd under provision of Chaptcr 9 (comnrcncing with Scction 7000) of Division 3 of the Busincss and Professions Codc. and my liccnsc is in full forcc and cffect. Liccnsc C-I W I hcrcby affirm undcr tf,nalty of Frjury that therc is a construclion lcnding agcrcy for thc lvforroncc of thc work for which this Jrcrmit is issucd (Scc. 3097, Civ. C.). Lcndcr's Narnc: I-cndcr's Addrcss: APPLICANT DT'CLARATION I hcrcby affrnn undcr pcnalty of perjury onc of thc following dcclarations: Dcmolition Pcrmits-Asbcstos Notification Fcderal Regulations (Titlc 40. Part6) _Rcquircd [rttcr of Notification _l ccrtify that thc fcdcralrcgulations rcgarding asbcstos rcn'nvalarc not applicablc to lhis projcct. _l ccrtity that I have rcad this application urd state that thc atnvc irtfornution is correct. I agrcc to conrply representativcs of this City with all City and County and County lo cnlcr uJnn thcordinances and Statc Laws rclating to building construction. abovc nrcntioncd propcrty lbr inspcction purg)ses. Applicant or Agent Pernritee nanre authorizc 6 7 9/to /e. I / "ln{ Section 3076 intcrcst ?7 Liccnse