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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATTON <br />I hcrcby lffirm undcr Fmlty of pcdury thal I am cxcmpt from thc Contraclorc' Liccns law for lhc following rtasn (Se.?Otl.5 <br />Business and Profcssion Codc): Any City or County which rcquircs a Jrcrmit to construcl. altcr, improvc. demlish or rclEirany <br />slructurc. prior to its issuancc, also requircs thc applicant for such |rcmit lo filc a sigred stqtcmnt that hc or strc is liccnsd pursuant <br />lo thc provisions of thc Contractor's Liccnrcd law (Chaptcr 9. Commcncing with Scction ?000 of Division 3 of thc Busincss and <br />Prcfcssions Codc) or that hc or shc is cxcmpt thcrcfrom and the btrsis for thc allcgcd cxcmption. Any violation of S$tion 703 1.5 by any <br />applicant for a pcrmit subjccts thc applicant to o civil pemlty of not morc than fivc hundrcd dollus ($500). <br />_1. as owncr of the propcrty. or my employccs with wagcs as theh solc conlpcnsation. will do lhc work and thc stnrcture Ls not <br />intcrded or offcrcd for salc (Scr.7044. Business and hofcssions Codc: Thc Contractor's Liccnse law docs not apply lo an owncr o[ <br />thc propcrty who builds or improves thcrcrn. and who dcrcs such work himsclf or hcrsclf or through his or hcr own cmployccs. <br />providcd that such inrprovcnrcnts are not intcndcd or ofIcrcd for sah. lf. howcvcr. thc building or improvcnrcnt is sold within onc ycar <br />of cornphtion. thc Owncr Buildcr will havc thc burdcn of proving that hc or shc did not build or improve thc propcrty for thc purJnsc of <br />salc). <br />_1, as owncr of the propcrty, ilm exclusivcly contracting with liccnscd contractors to construct thc projcct (Scc. 7U4, Busincss <br />and hofession Code: The Contractor's Licensc Law docs not apply to an owner of property who builds <lr improves thcrcon. <br />and who contracts for such projccts with a Contractor(s) licensed pursuant to thc Contractor's Liccnsc Law). <br />-lamexelnptundcrScction-.B.&P.C.forthisrcason.Dale: Owner:- <br />WORKERS' COM PF'NSATION <br />DECLARATION <br />I hcrcby affirm under pcnalty of perjury onc of thc following declaratiorts: <br />-lhavcadwill <br />rointsinoCcrtificatcofConsenttoScl[lnsurcforeorkc]s'con[rcnstion,as prcvidcdforbySstion3T00oflhc <br />h!9r fue. for thc tErformrcc of thc work for which lhc Ircmit is issucd. <br />Vfl havc and will mainrain workcrs' compcnsrtion insuruncc. as rcluircd by Selion 37OO of ttrc tibor Code, for the pcrfomncc of <br />thc work fbr which this Jrcrmit is issucd. My workcrs' omlrcnsali(rn insurarcc cunicr ord policy numbcr rc: <br />t <br />]-o'rior la2Policy <br />_l certify that in thc Jrcrformancc of thc work for which this prcrmit is issucd. I shall not cmploy any pcrson in any manncr <br />so as to becomc subjcct to thc workers' compcnsation laws of Calitbrnia. and agrcc that if I should bccome subjcct to thc <br />workcrs' compcnsation provisions of Section 3700 of thc l.-abor Code. I shall. forthwith comply with thosc provisions. <br />WARNING: Failurc lo sccurc workcrs' cotnpcnsation and shall an crnpkrycr to crirninal penaltics and <br />civil fincs up to one hundrcd thousand dollars ($100,000),Io lhc damagcs as providcd for the <br />allorlrcy's l'ccs. <br />I <br />I hcreby affirnr undcr pcnalty of prjury thal I anr liccnscd undcr provision Chaptcr 9 (commcncing with Scction 7000) of Division 3 <br />of thc Business and Profcssions Codc, alrd nry liccnsc is in full force ard cfl'cct. <br />t <br />a to Nunrbcr: F 6L+L(1Liccnsc']o 2-l <br />W <br />I hcrcby affrm undcr lrcnalty of pcrjury Ihar thcrc is a construction lcnding agcmy for thc Frforrorcc of thc work for which this tsmil ir <br />issucd (Scc. 3097. Civ. C.). <br />lxndcr's Namc: <br />Lcndcr's Addrcss: <br />APPLICANT DECLARATION <br />I tnrcby affmn under pcnalty of perjury onc of thc following declarations: <br />Dcnrolition Pcrmits-Asbcstos Notification Fcdcral Rcgulations (Title 40. Part6) <br />Rcouircd [rttcr <br />-An"rhat <br />thc <br />f*"-irv rr,rr I have <br />ol'Notilication <br />tbdcral rcgulations rcgarding asbcstos rcmovalarc not applicablc to this projcct. <br />rcad this application that thc atxrvc inftlrnration is corrccl. I agrcc to cornply with all City and County <br />ordinanccs and Statc laws rclating to of this City and County to enter upon thc <br />rlo,a o oB l'u lz'atxrve nrcntioncd propcrty for inspection <br />Applicant or Agent <br />( t &ltotl'ernritee nanle <br />K <br />and <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loo r/Ve nt/l ns u I atio n <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsu lation/Enerqy <br />Drvwall <br />Ext./!nt. Lath <br />Brown Coat <br />N/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif. <br />ll ^ tL rt / <br />FINAL qtc0 'l {t}t{.6q <br />Certificate of Occupancy ll <br />Notes, Remarks, Etc. <br />_Expircs: <br />Scction 3076 of thccc)LS Applicant: <br />u","' t 0 6f <br />Contracto.L