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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby allinn uMcr pcnnlty ot pcrjury lhal I am cxcmpl fftnn lhc C(nilraclors' Lkcns lnw for thc following rcason (Scc.7031.5 <br />Busittcss and Profcssiqr Codc): Any Cily or Counly which rcquircs a Jrnnil to @nstruct. allcr. imprcve, demolish or rcplir any <br />rlruclurc. Jrk)r kr ils i$sunncc. also rcquircs lhc applicanl for such pcrmit lo filc a signed statcrcnl that hc or shc is liccnscd pursuanl <br />to lhc pmvisi(ilrs of lhc (:onlraclor's l,iccnscd law (Chnplcr 9. Commcncing with Scction 7000 of Division 3 of lhe Business and <br />Profcssions Codc) or th{t hc or shc is cxcmpt thcrcliom and lhc busis for thc ullcgcd excmplion. Any violation of Scctiotr 70-1 I .5 hy any <br />applicuot li)r a lrcnDit suhjccts thc applicant to 0 civil pcnalty of not nhrc than five hund.cd dollars (S500). <br />-1. <br />as owncr of lhc propcrly. or my cnlployccs with wages as lhcir solc cotnpensalion. willdo the work and thc struclurc is lxrl <br />intcltclctl ()r otl'crcd lbr salc (Sct.7()44. Busincss and hofessions Code: The Contractor's Liccnse Law docs not apply to an owner o[ <br />lhc pnrpcrly who builds or irnprovcs thcrcon. and who clrrcs such work hirnself or hcrsclf or through his or her own cmployccs. <br />providcd that such irnprovenrcnls arc nol inlcnclcd or olTcrcd for salc. ll. hou,cvcr. thc buikling or irnprovenrcnt is sold within onc ycar <br />of conrphlion. thc Owncr Buiklcr will have thc burdcn of proving lhat hc or shc did not build or improvc thc propcrty for thc purprseof <br />salc). <br />-1. <br />as owner of thc proJrcrty. am cxclusivcly contracting with liccnscd conlractors to construct thc project (Sec. 7044. Busincss <br />and Pnrfbsshn Code: Thc Contraclor's l-iccnsc Law docs not apply to an owncr of proJrcrty who builds or improvcs thercon. <br />and wh<l conlracls lirr such projccts with a Conlraclor(s) liccnscd pursuant to lhc Conlractor's Licensc Law). <br />-latlrcxcmplundcrSection-.B.&P.C.forthisrcastln.I)ale:Orr ner: <br />WORK FRS' COIITPENSATION <br />DECLARATION <br />I hcrchy ufl'irnr undcr pcnalty of prjury onc of thc following dcclarations: <br />-l <br />havc arxl will mainlain a Ccrlificatc of Consent lo Self-lnsurc for workers'comlrcnsation. as providcd for by.Section 37fi) of thc <br />lahr Ctdc. for lhc Jrcrfirnnance of thc work frlr which thc pernrit is issued. <br />-l <br />havc and will ntuintaitt wrtrkcrs' contpcnsal ion irtsurancc. as rcquircd by Scct ion .17fi) of the Labor Code. for thc Jrcrfornuncc of <br />tltc wttrk lirr which this pcrrnit is issucd. My workcrs' compcnsation irrsurancc carricr and prlicy numbcr are: <br />Policy Nunrbcr: Expircs: <br />-l <br />ccrlity lhal in thc pcrfrrrmattcc of thc wrlrk lbr which this pcnnit is issucd. I shall not enrploy any person in any mflnncr <br />so astohccotttcsubjccttothcworkcrs'cornpcnsalionlawsofCalifornia.andagrcethatiflshouldbccomesubjccttothc <br />workcrs' cotnpcttsal ion provisions ol' .Scction 37(X) of thc Lrhrr Coclc. I shall. l'orthwith cornply with those provisions. <br />WARNIN(i: Failurc lo sccurc workcrs' cornpcrrsalion covcragc is urrlawlul. and shall subjcct an cmploycr to crinrinal Jrcnaltics and <br />civil lincs up lo onc hturdrcd thousancl dollars ($l(ru.(XI)). in addition to thc cost of cornpensation. damages as provirletl f'or thc <br />Scction 3076 of thc l-atxrr Codc. intcrcsl tnd altorncy's t'ccs. <br />l)nlc:_ Applicant:_ <br />LICF'NSEN CONTRACI'OR <br />NECLARATION <br />I hcreby alllrlrt undcr pcnalty of pcrjury lhal I anr liccnscd undcr ;rrovisiorr of Chapler 9 (colnmcncing with Section 7m0) of Division 3 <br />of thc Busirtcss and Profcssiorts Codc. and rny liccnsc is irr l'ull torcc alrd elfcct. <br />Liccnsc Class: l,iccnse Nunrber: <br />l)nle:Contraclor:_ <br />CONSTRUCTION LFNDING AGENCY <br />I hcrchy allirm undcr pnahy of pcrjury lh{l thcrc is a cuslrudhn hnding agcncy for thc lcrfonruncc ofthc work for Bhich lhis lErmit is <br />issucd (Scc. 3(fr7. Civ. C.). <br />ltndcr's Namc: <br />kndcr's Adrlrcss: <br />APPLICANT DT'CLARATION <br />I hcr,-by allrrnr undcr Jrcnalty of pcrjury onc of thc followirrg dcclarations: <br />Dcnm l il ion Pcrnrit s- Asbcstos Not if'icat iolr Fcdcral Regu lat ions (Tit le 40. Part6 ) <br />-Rcquirctl <br />kllcr of Notilication <br />-l <br />ccilify thal thc fcdcralrcgul8lions rcgfrling ashcslos rctnovalarc nol applicablc lo this prcjcct. <br />-l <br />cenify lhal I havc rcud this application and stslc lhil thc *nvc informtion is corccl. I agre lo omply with oll Cily and County <br />onlinanccs und Statc taws rclatingi io huilding construction. and lgJry authorize rcprcsntatives of this City and Counlyto entcr u[nn thc <br />atnvc mnti(rncd nmrcrtv for insmtim numrcs. Z/- <br />ApprrcsnrorAsenrsr*r,,u*,.{ <br />t-t <br />L *,., 'O1 [tt lotOlt <br />Permitee name (prirr), Y- +Ntl tlO <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bf loor/Ve nt/l n s u lat ion <br />Roof Sheathing <br />Shear Wall <br />Framing <br />lnsulatio nlEnergy <br />Drvwall <br />Ext./lnt. Lath <br />Brown Coat <br />N/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />--a-=aFlood Zone Certif .EXPtr ErJ <br />aral <br />JUL I, I ctab t <br />FINAL -ro rA q,R 366.007 <br />Certificate of ncy EAruw \r'-wvr -- <br />Notes Remarks Etc.