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BUILDING- INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG COMMENTS OWNER BUILDER DELCANATION <br />I hcrcby affirm undcr Fnalty of Frjury th.t I m excmpt fmm the ContractoE' Liensc liw for thc followitrg M$n (58.7031.5 <br />Busincss and Prcfcssion Codc): Any City or County which requircs a pcrmit lo @nslruct. alts, imprcvc, dcmllsh or rcpair ey <br />structurc, prior to its issuarcc. also rcquircs thc applicant for such Frmit to filc a sigrcd statcrcnt that he or shc is liccnsed pursuant <br />to thc prcvisions of thc Contractor's Licen$d law (Chaptcr 9, Commncing wilh Sslion 7000 of Division 3 of thc Busiress 8nd <br />hofcssionsCodc)orthathcorshciscxemptthcrcfromandthcbasisforthcallcgcdcxcmption. AnyviohlionofSctionT03l.5byony <br />applicant for a pcrmit subjccts the applicanl to a civil pculty of not nErc thon fivc hundred dollds ($500). <br />_1. as owncr of thc propcrty, or my cnlployccs with wagcs as their solc compcnsation. will do thc work and the stnrcturc is not <br />intcndcd or offcrcd for salc (Scr.7044, Busincss and hofessions Codc: Thc Contractor's Licensc Law does not apply lo an owncr of <br />thc propcrty who builds or inlproves thcrcon. and who docs such work hinrclf or hersclf or through his or hcr own employecs, <br />providcd that such improvenrcnts arc not bltcndcd or offcrcd for salc. If, howcvcr. thc building or improvcrEnt is sold within onc )rcar <br />of conpletion. thc Owner Builder will havc thc burdcn of proving tlurt hc or she did not build or improve thc proprry for thc purgnsc of <br />salc). <br />-1. <br />as owncr of thc prolrcrty, am cxclusivcly contracting with licenscd contractors to construct thc projcct (Sec. 7W, Busincss <br />and Pmfbssion Codc: Thc C<lntractor's License Law docs not apply to an owner of propcrty who builds or improves lhcrcon, <br />and who contracts for such projects with a Contractor(s) licenscd pursuanl to thc Contractor's Liccnsc taw). <br />-Iamcxcn1ptunderSection-'B.&P.C.forthisrcason. <br />flola. llunor. <br />WORKERS' COMPT'NSATION <br />DECL{RATION <br />I hcrcby affirm undcr pcnalty of pcrjury onc of thc following declaratiorrs: <br />_l have ud will rnaintain a Certificate of Consent to Sclf-lnsurc for workers' compcnsation. as provided for by Scction 3700 of thc <br />Lahor Codc. for thc pcrfornrancc of the work for which thc pcrmit is issucd. <br />-l <br />havc and will maintain w<lrkcrs'compcnsation insurancc, as rcquircd by Scction 3700 of thc Lahor Codc. for thc pcrformancc of <br />thc work for which this pcrrnit is issucd. My workcrs' compcnsation insurancc carricr and plicy nutnber iuc: <br />-rtA yt <br />Poricy*,*n",, ' [J AWcrJ q 5/{ Expircs: <br />J <br />_l ccnify thal in thc lrcrformnce of the work for which this prmit is issucd. I shall not cmploy any 1rcmn in any manrcr <br />s as to bcrom subj$t to thc worktrs'otrrpcnsation hws of California. and agrc that if I slDuld bccorc subjst Io Ihc <br />workcrs'onrpcns.lionpmvisionsofSmtion3T00ofthctiborCodc.lshall.fonhwithcomplywiththorcprcvisions. <br />WARNING: Fililurc to suc workcrs' compcnsation svcmgc is unlawful. and shall subjcct a cmploler to oiminal tEmllies and <br />civil fincs up to onc hundrcd thousand dollars ($100.000). in to lhc cost of comlrcnsation, damages as provided for the <br />Scction 3076 of Labor Codc, interest and altorrrcy's fccs. <br />t-t <br />I)ECI ,\RA'I'I0N <br />I hcrcby atlirm under pcnalty of prjury that I am licensed undcr provision of Chaptcr 9 (comnrcncing with Sectbn 7000) of Division 3 <br />of thc Busirrcss and Profcssions Codc. and nry licensc is in full forcc and cffcct. <br />a <br />Liccnsc ?t <br />t <br />W <br />I hcrcby afftrm undcr Fmlly of pcrjury that thcrc is s @nstruction hnding agcncy for thc lErformrcc of thc work for which this pqmit is <br />issucd (Scc. 3097, Civ. C.). <br />lrndcr's Namc: <br />APPLICANT DECLARATION <br />I hcrcby atfirm undcr pcnalty of pcrjury onc of thc folkrwing dcclarations: <br />Dcmolitkrn Pcrnrits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40, Part6) <br />_Rcquircd Lcttcr of Notification <br />-l <br />ccrtify that thc l'ederal rcgulations rcgarding asbcstos rcmovalarc not applicablc to lhis pnrjcct. <br />S!, certify that I have reud this application and statc that the abovc information is corrcct. I agrcc to comply <br />ordinanccs and Statc l^aws rclating to building construction. ard hcrcby authorizc rcprcscntativcs of this City <br />with all City and County <br />and County to cntcr ugrn thc <br />abovc nrcntioncd propcrty for inspcction I <br />Applicant or <br />IDermitee <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenUl nsu lation <br />Roof Sheathing <br />Shear Wall I I <br />Framinq vl ,l 'hlL bfl'V6n,/ <br />Insulatio nlEnergy I I <br />Drvwall ,l <br />Gxt]lnt. Lath (I p*r?/ <br />Brown Coat q 'r,,i ,'7-l Dk# *4 7 <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 />I ,l .< D/ <br />FINAL LO Dltr)ru o <br />Certificate of Occupancv I <br />Notes, Remarks, Etc. <br />-t <br />zlp r <br />lrndcr's Address: <br />,,r",. ulll ll 2( <br />( <br />l7 (/'