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INSPECTOR RECORD ) SITE.WORK DATE !D/SIG COMMENTS OWNER BI'II NER DELCARATION I hereby affinn under penalty of perjury that I am exempt fonn the Contractors' License Law for the following reason (Sec.703l ..5 Business and Profession Code): Any City or ('ounty rvhich requires a Jrcrrnit to construct. alter. improve. demolish or repair any structure. prior to its issuance. also rcquires the applicant ficr such grennit to file a signed statement that he or she is licemed pursuant to ttre provisions of the Contractor's l.icensed Lau,(Chapter 9. ('ornmencing with Section 7000 of Division 3 of the Business and Professions Code) or that he ff she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031 .5 by any applicant for a pcrmit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). *9 l. ". owner of the property. or my ernployees with rvages as their sole cornpensation. rvilt do the work and the structure is not inrended or offered for sale (Sec.7044. Business and Professions Code: The Contractor's l.icense larv does not apply to an owner of the Foperty rvho builds or improve thereon. and s,ho does such rvort himself or herself or through his or her orvn employees. provided that such imp,rovements ane nol intended or offered for sale. If. hos'ever. the building or imp,rovenrent is sold s'ithin onc year of complaion. the Ou,ner Builder rvill have the burden of proving that he or she did not build or improve tre properW for the purpcse of sale). No I. ". owner of tlre property. am exclusively contracting rvith licensed contractors to construct the projecl (Sec. 7044, Business and hofession Code: I'he Contractor's l.icense Law does not apply to an owner of property who builds or improves thereon. and rvho contracts for such projects rvith a ('ontracto(s) licensed pursuant to the Contractor's License Law). !! I arn erempt uncler Section . B. & P.C. for this reason. WORKF'RS' COM PFNSATION DTCI ARATION I hereby afTinn under penalty of perjury one of the following declaratiom: !-t fr."" and s,ill maintain a Certificare of Consent to Self-lnsure for workers' compensation. as providcd for by Section -1700 of the l.abor Code. for the performance of the rvork fior rvhich the pcrmit is issued. YES _ I have and rvill maintain workers' cornpensation insumnce. a.s required by Section .1700 of the Labor Code, for the pcrformance of the rvork for which this pennit is issued. My worters' compensation insurance carrier and policy number are: . Safety Natlonal Gaeualty( arner: ro40GlG02 04iO1,2O22 Policy Nurnber: Expires: NO I cer1ifo tlrat in the perfonnance of lhe work for u,hich this pennit is issued. I shall not employ any penson in any rnanner so as lo becorne subiect to the n,orkers' compensation larvs ol'('alifornia. and agree that if I should become sub.iect to the rvorkers' cornpensation provisions of Section 1700 of the Labor C'ode. I shall. forthrvith comply rvith those provisions.. \['ARNIN(i: Failure to secure worters'comgrnsation coverage is unlarvful. and shall subiect an employer to criminal penalties and civil fines up to one hundred thousand dollars ($100.000). in addition to the cost of compensation, damages as provided for the Section 3076 of the Labor Code. interest and attomey's fc.es. LICFNSFN CONTRACTOR DECI AR ^TION I herebl'affinn under penalty of pr.iury that I am licensed undet provision of Chafler 9 (commencing with Section 70m) of Division .1 of the Business and Professions Code. and my license is in firll force and effect. ABC3C I -icense ('lass:1028880 l.icense Nurnber CONSTRI.ICTION I FNNING AGTNCY I hereby' affinn under penalty of perjury that there is a construction lending agency for thc perfornrance of the work for which this permit is issued (Sec. 1047. Civ. C.). I .cntler's Narne: l-ender's Address: APPI IC^NT NFCLTRATION I heretrv ali'inn under penalty of per'lury one of the followrng declaratrons' Denrolition Pennrts-Asbestos Notrlication Federal Regulalrons (Title 40, Part6) Ni Required l.etterof Notification Y1 I ceniry' that rhe federal regulations regarding asbestos removal are not applicable to this project. YEs I cerliS, lhat t lrave reacl this applicarion and state that the above infi'rrrnation is con'ect. I agree to comply rvith all City ancl ('ounty ordinances and State l-an,s relaling to building constnrction. and hereby authorize representatives of this City and County'to enter upon the above ment ioned propert)' for inspect i()n purposes. Reroof Roof (Draphragm Sheathing/Frame) Structural Final Plumbing --) \ Under Floor I Under SIab q-y)-Ll &)fr Rough \2 Shower Pan / Tub Test Water Service Sewer / Sewer Cap Gas Air Pressure Test ,^\ Plumbing Fina!1-b-zL TID BT Electrica!\-/ Service (Meter I Panel) Grounding / Bonding Rough Electrical Final Mechanical Gas Air Pressure Test Rough Piping (HW, CW, etc.) Exhaust Ducts Mechanical Final Notes, Remarks, Etc.