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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcrchy atl'irm undcr pcnally of JErjury that I am cxcmpt from lhc Curlracklrs' Liccnsc kv lor lhc lirll(rwing rcd$rn (Scc,70ll,5 <br />Busincss anl Protbssion Culc): Any City or County vhich rcquircs a JEmit k) construcl. alter. improve. dcmolish or rcpair any <br />slructurc, pror b its issuancc, also rcquircs the applicant lbr such lErmit to lilc a signed statcrcnt that hc or she is'licIr*d pgrsuant <br />to thc pn visions of lhc CoDtrackrr's Liccnscd liw (Chaptcr 9. Commncing with Sslion 7fi)0 of Division 3 of rl. Busi{;s'anrl <br />Prrfcssions Crdc) or that hc or shc is crcmpt thqcfrom and the basis ti)r thc allcgcd cxcmption. Atry violNtion of Scctiotr ?03 1.5 by any <br />{pplicalt for a [rrmit subjsls thc applicatrt to a civil pcnalty of not morc than tivc hudrcd dollds ($5U)). <br />_1, as owncr ol'tlrc proF,*rty, or my cmpk)yees with wagcs as thcir solc cotnpcnsalion, will do thc work and thc structurc is nol <br />intcndctl or ()thrcd for salc (Sc-*.7044, Busincss and Professirlns Culc: Thc Contractor's [.iccnsc [-aw docs nol apply to an owner of <br />thc proJrcrty who buikls or irnpr)vcs thcrcrrn. and who dtrcs such work himsclf or hcrscll'or through his or hcr own cmployccs, <br />prlvrtlcrl that such impnrvcnrcnts arc mrt intcndctl or ()tl'crcd lirr sah. Il, howcvcr. thc buikling or impr)vcrncnt is sokl within onc yc:u <br />ol'complction, thc Owncr Buiklcr will lurvc tlrc burdcn ol'proving that hc or shc did not huikJ or improvc thc propcrly for the puryx)sc of <br />salc). <br />_1, as()wncrol'the pft)pcrty, amexclusivclycontracting with liccnscd conlractors to conslruct thc prcjcct (Sec. 7044, Busincss <br />and Pnrtbssion Corlc: Thc Contractor's Liccnsc l-aw docs not apply to an owncr of propcrty who buikls or improvcs thercon. <br />alrd who contracts tirr such projccts with a Contractor(s) liccnscd pursuant to lhc Conlractor's Liccnsc Law). <br />-IamcxcmptundcrScctirln-'B.&P.C.lilrthisrcastltt.It.,r^. <br />WORKERS' CO[\I PENSATION <br />DECLAITATION <br />I hcrcby all'irrn undcr Jrcnalty of pcrjury onc of thc tirlkrwing dcclarations: <br />_I havc aril will maintain a Ccrtilicatc of Conscnt to Scll'-fulsurc for workcrs' comJrcnsation, as pnrvidcd firr hy Scction J700 of thc <br />Lahlr Codc. lirr the lrcrtirrmancc of thc wrlrk for which thc Jrcrmit Ls issucd. <br />_l havc and will maintain workcrs' comFrcnsation insurancc, as required by Scction -17fi) of thc Lahor Codc, lbr thc ;rcrftlrmance of <br />thc wrlrk filr which this permit is issued. My workcrs' comlrcnsation insurance carrier arxl pllicy numbcr arc: <br />.a <br />5 <br />Policy a <br />_l ccrtily that in thc'Jrcrlirrmancc of thc work tirr which this is issucd, I shall not cmploy any lrcrson in any matrncr <br />so as to bccrlmc subjcct ttl thc workers'compcnsation laws of and agrcc that if I slxrultl bccomc thc <br />workcrs' comJrcnsation provisions ol'Scctiun -17fi) ol'lhc Lahlr I shall, firrthwith comply with thosc <br />WARNING: Failure lo sccurc workcrs' comJrcnsatiorr is and shall suhjcct an cntploycr Jrcnalties and <br />civrl litrcs orrc huntlrcrl thousand dollars ($l(ru,fim),cosl ol'conrpcnsal iott,as providcd lirr thc <br />Scction thc l;rhor Crxlc. intcrcst altorncy's t'ccs. <br />3 <br />I hcrchy al'lirnr undcl <br />ol' llrc Busitrcss and <br />ol'pcrjury that I am licenscd 9 with Scction Division 3 <br />{! <br />, <br />Codc, antl my licensc is in full lilrcc arttl cll'cct. <br />I-iccnsc J <br />(.0NS'I'RI,'(]TI()N I,I]N DI NG,\(; FINCI' <br />I hcrcby utlirm undcr [EMlty of pcrjury thst thsc is a conslructhn bndinS agcmy for the lErformncc of thc vork for shich this Isnit is <br />issucd (SN. .1097, Civ. C.). <br />l*ndcr's Namc: <br />[,cndcr's Addrcss: <br />APPLICANT DECLARATION <br />I hcrcby all-rm undcr pcnalty of pc{ury onc of thc lillkrwing declarations: <br />Dcmolil ion Pcrnrit s-Asbcstos Not ificat iorr Rcgulatkrns (Titlc 40, Part6) <br />Rcourcd l.cttcr+ <br />) <br />-, <br />/",,,,, thar thc <br />h,.1,ffi"" <br />ol Nolilicirliott <br />ll'dcral rcgulations ashcstos rcmovalarc not applicablc to <br />rcad lhis thc inlilrntatiott is corrcct. I to contply with all City antl County <br />City County lo cntcr ugrn lhc <br />atxrvc nrc-ntioncd propcrty ftlr <br />Applicant or Agenl <br />I /--) <br />Pentritee nanle <br />atil authorrze <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf Ioor/Ve nt/l n su latio n 7 <br />Roof Sheathing <br />Shear Wall <br />Framing <br />lnsu lation/Energy rl <br />Drywdla a.rLl o( <br />Extfint.)ZL <br />BroknfCoat I <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />FINAL lD-{-zt D-<' 4u <br />Certificate of Occupancy <br />Etc. <br />[" I l.l ?( ./P t1 \h$A / lA-r1.,,1- D*yE7r/I' I t rl <br />-+ <br />Parr nQ-n7 -)n 1 q <br />0 U <br />0 <br />rlI .) <br />ta /