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BUILDING- INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby affirm undcr penalry of pcrjury that I m cxcmpt frcm thc Conl]aclo6' Licenrc l:w for thc following rcarcn (54.7031.5 <br />Busincss and Profcssion Code): Any City or County which rcquircs a Jrrmit to construct. altcr, improvc, dcrclish or rcpaL any <br />structurc. pdor to ils issuamc, also rcquircs thc applicant for such Frmil to file a sigrcd statcrcnt th.t hc or dlc is liccnsd puru8nt <br />to thc prcvisions of thc Contractor's Liccnwd law (Chaptcr 9. Cornncncing wilh Scction 7000 of Division 3 of thc Busincss and <br />Prcfcssions Codc) or that hc or shc is crcmpt thscftom and thc basis for lhc allcgcd exemption. Any violation of Sethn 703 1.5 by any <br />applicant fbr a permit subjccts thc applicant lo a civil pcnalty of not mrc lhil fivc hundrcd dollms ($500). <br />_1. as owncr of the proprty, or my cmployccs with wagcs as thcir slc compcnsation. will do the work and the slructurc is not <br />intcndcd or ofl'cred for salc (Scc.7044. Business and hof'cssions Codc: Thc Contractor's Licettsc Lrw docs not apply to an owner of <br />thc propcrty who builds or improvcs thcrcon, and who docs such work himsclf or hcrsclf or through his or hcr own cmployccs. <br />providcd lhat such intprovcnrcnts arc not intendcd or otlcrcd frlr salc. lf. howcvcr. thc building or improvctrrcnt is sold within onc ycar <br />of corrrplction. thc Owner Buildcr will havc thc burdcn of proving that hc or shc did not build or improvc the properly for thc purpnsc of <br />sah). <br />-1. <br />as owncr of thc proprty. am cxclusivcly contracting with liccnscd contractors to construct thc projcct (Scc. 7W, Busincss <br />and Profbsskrn Codc: Thc Contractor's Licensc Law docs not apply to an owner of propcrly who builds or improvcs thcrcon, <br />and who contracts for such projccts with a Contracto(s) liccnscd pursuant to thc Contractor's Liccnsc taw). <br />-IatncxcmptundcrSection-.B.&P.C.lbrthisrcason. <br />I\... ^. <br />IIQ8TE&I:I]TIMPINSAIION <br />DECIdSAIION <br />- I hercby allrm undcr pcnalty of pcrjury orc of lhc following dcchmtions: <br />-l <br />havc and will miltoh a Ccnificarc of Conrcnt to Self-lnsurc for workcs' comlEnstion. as pmvidcd for by S(tion 3700 of fic <br />lilr thc lrcrfornuurcc of thc work frrr which thc pcrnrit is issucd.LaborzCodc, <br />Ar" onowill nrairrtain workcrs' compensati<ln insurancc. as by Scction 3700 of the Labor Codc, for thc;rcrformance of <br />,carricr and plicy numbcr arc:thc work for this pcrrnit My <br />0 z <br />_l ccnify that in Ihc pcrforrmrcc of thc work for which this pcrmit is issucd, I shrll not cmploy any pcrson in any nunrcr <br />w astobc@msubj€ttothcworkffs'omlrcnsationlawsofCalifornia.andagrclhatiflshouldbccomsubjccttolhc <br />workss'@mpcnsationpmvisionsofScction3T0OoflhetibrCodc.lshall.forthwilhcomplywiththosprovisions. <br />WARNING: Failurc lo $curc workers'compcnsation covcrogc is unlawful, and shall subjcct e cmploycr to siminal lrcmltbs and <br />civil fincs up to onc hundrcd thoosand dolles (SI00,000), in addition to lhe cost of comJEnsation, damgcs as providcd for thc <br />Section thc Codc. intcrcst and attorncy's <br />/ <br />I hcrcby atfirm undcr pcnalty of perjury that I arn liccns;ed undcr provision of Chaptcr 9 (comnrcncing with Scction 7000) of Division 3 <br />of thc Busincss and Profcssions Code. and rny licensc is in full force and cffcct. <br />5 5t/ uBNurnbcr: <br />1 z <br />W <br />I hcrcby amrm undcr Fmhy of Frjury that thcrc is a constructirn hndin8 agcncy for thc ;xrforrorce of the work for which thls Frmit is <br />issucd (Se. 3097, Civ. C.). <br />hndcr's Nsmc: <br />Lendcr's Address: <br />APPLICANT DECLARATION <br />I trcrcby affirm undcr pcnalty of perjury onc of the following dcclarations: <br />Demolition Permits-Asbcstos Notification Federal Rcgulations (Titlc 40, Part6) <br />-Requircd <br />lrttcr of Notificalkrn <br />_l ccrtify that the fcdcral rcgulations rcgarding asbcstos rcmoverlarc not applicablc to thls projcct. <br />I ordirranccs and Statc Laws relating to building construction. and hcrcby authorizc <br />is corrcct. I agrce to comply with all City and County <br />r rcprcscntativcs of this City and County lo enter upon the <br />abovc mcnlioncd propcrty for <br />[,'Applicant or Agent <br />frfermitee <br />n&me <br />LO IL <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenVl nsu lation <br />Roof Sheathinq <br />Shear Wall <br />Framing <br />Insu lation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />-l\/asonry <br />Pool Fence \ <br />T-Bar \ <br />Handicap Req \ <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />FINAL 9zo w(P-(!-Za -oJLsJ-o 2Y7 \ <br />Certificate of Occupancv <br />Notes, Remarks, Etc. <br />/ <br />Owner:-- <br />_F.xpircs: <br />L