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BUILDING. INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby aftirm undcr pcmlty of Frjury Ihat I m cxempt frcm thc ContnctoN' Lbensc ljw for thc following rclsn (Scc.7031.5 <br />Busincss ard Profcssion Codc): Any City or County which rcquircs s pcrmit to construct. alter. imprcrc. dcmlish or rcpair my <br />structurc, prk r to its issuece, also rcquircs lhe opplicsnt for such [Ermit lo filc a sigincd statcrcnl that hc or slE is liccnscd puBuant <br />to thc prcvisions of thc Controctor's Liccnscd [aw (Chaptcr 9. Commcncing with Sction 7000 of Division 3 of ]hc Busincss and <br />Pmfessions Codc) or that he or she is cxcmpt thtrcfrcm and the b&sis for thc alleScd cxcnrption. Any violalion ofs4liotr 703 1.5 by atry <br />applicant for a pcnnit subjcls thc upplicanl lo a civil pcmlty of not morc than fivc hundr€d dollus ($500). <br />_1. as owncr of thc propcrty. or my cmployccs with wagcs as thcir solc compcnsation. will do thc work and thc structurc is nol <br />intendcd or ofl'ercd fbr sale (Scc.7O+4. Business and Profcssions Codc: Thc Contractor's Liccnsc [-aw docs not apply to an owncr of <br />thc proJrcrty who builds rlr inrproves thcrcon. and who docs such work hinrsclf or hcrself or through his or hcr own cmployccs. <br />providcd that such improvernents arc not intcndcd orolfcrcd frrr salc. If. howcvcr. thc building or inrprovcnrnl is sold within onc ycar <br />of conpletion, thc Owncr Builder will havc thc burden of proving that hc or shc did not build or improve the propcrty for thc purposc of <br />sah). <br />-1. <br />asowncrof the propcrty, arnexclusivclycontracting with liccnscd cotrtraclorstoconslruct thc projcct (Sec.7W, Busincss <br />and ProtLssion Code: Thc Contractor's Liccnsc Law docs not apply to an owner of propcrty who builds or improvcs thercon. <br />and <br />-I <br />who conlracts ttrr such projccts with a Contractor(s) liccnscd pursuant to thc Conlraclor's Licensc Law). <br />Section-, B.lbr <br />-I t1 LI <br />I hcrcby affirm under pcnalty of pcrjury one of the following dcclarations: <br />-l <br />have and will maintain a Ccrtificatc of Consent to Sclf-lnsurc for workcrs' corrpcnsation. as providcd for by Scction 3700 of thc <br />Labor Codc. for thc pcrformancc of thc work for which thc permit is issucd. <br />-l <br />havc and will maintain workcrs' compensalion insurancc, as requircd by Scction 3700 of thc labor Codc, for the lrcrformancc of <br />thc work for which this pcrmit is issued. My workcrs' compensation insurance carricr and plicy number are: <br />Policy Number: Expires: <br />-l <br />ccrtity that in thc lrcrformancc of thc work for which this pcrnrit is issued. I shall not cmploy any l&-rson in any manncr <br />so as to bccorrc subjcct to thc workcrs'comJrcnsation laws of California. and agrce that if I strould bccome subject to thc <br />workers' cornpcnsation provisions of Sccti<ln 3700 <lf the Latxlr Codc. I shall. ltlrthwith conrply with thosc provisions. <br />WARNING: Failurc to sccure workcrs'compcnsation covcragc is unlawful, and shall subjcct an cmploycr to criminal Jrcnaltics and <br />civil fines up to onc hundrcd thousand dollars ($100,000), in Io c<lrrrpcnsation. darnagcs as providcd for th,r' <br />Scction 3076 of thc intcrcst and attorncy's fccs. <br />o t1,t1 <br />I hcrcby allirnr undcr pcnalty of prjury that I am liccnscd undcr provi.sion of Chaptcr 9 (commcncing with Scction 7000) of Division 3 <br />of the Busincss and Profcssions Code, arxl my liccnsc is in t'ull forcc and cffcct. <br />Liccnsc Class: Liccnse Numbcr: <br />W <br />I hcrcby affirm undcr Fnalty of Frjury lhal lhcrc is a construction lcnding agcncy for the prfomuncc of thc work for which this Imit is <br />issucd (Sec. 3097, Civ. C.). <br />Lrndcr's Nanrc: <br />[.cnrlcr's Atldrcss: <br />APPI ICANT NECLARATION <br />I hcrcby alilrm undcr pcnalty of pcrjury onc of thc following dcclarations: <br />Dcnrolition Pcrrnits-Asbcstos Notification Fedcral Rcgulations (Titlc 40. Part6) <br />-Rcquired <br />[,etter of Notification <br />-,* <br />ccrtify that thc <br />il *nnrrhar t havc <br />federal regulations rcgarding asbcstos rcntovalarc not applicable to this projcct. <br />rcad this application and with all City and County <br />and County to enter upon thc. rlttlu <br />ordirranccs and Statc Laws rclating to <br />abovc rrcntioned property for inspcction <br />Applicant or Agenl <br />Pernritee nanle <br />that thc ahlvc <br />ll.rlrr. <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bf I oo r/Vent/l ns u latio n <br />Roof Sheathinq <br />Shear Wal! <br />Framinq <br />!nsu Iation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Jtlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif . <br />n <br />FINAL ,Jr/t /,/7,\ <br />Certificate of Occu <br />Notes, Remarks, Etc.I <br />Carricr:_ <br />Date:_Contractor: