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BUILDING. INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDEN DELCARATION <br />I hcrcby affirm undcr pcnally of pcrjury lhal I am exempt frcm Ihe Conhaclors' Lisnsc lrw for thc following rca$n (Scr.703l.5 <br />Busincss ard Profcssion Codc): Any Cily or County which rcquircs a Frmit to conslruct, altcl improve. dcmlish or rcpair any <br />slruclurc. prior to its issuancc. also rcquircs thc applicanl for such JErmit lo tilc l signcd slatcmnl that hc or shc is liccnscd pursuanl <br />to Ihc previsions of thc Controctor's Liccnrcd law (Chaptcr 9. Conrnrcncing wilh Sstion 7000 of Division 3 of Ihc Busircss ind. <br />Profcssions Codc) or lhat hc or shc is cxcmpt thcrcfronund thc basis for thc alhgcd cxcmption. Any violalion ofSmtiotr 7011.5 by any <br />applicant for a pcnnil subjsls thc opplicanl k) o civil pcnahyof nol [D]c thM fivc hundrcd dollars ($500). <br />_l.as owncrofthepropcrty.ormyemployeeswithwagcsasthcirsolcconlpensalion.willdolhcworkandthcstnrcturcisnot <br />intcndcd oroflcrcd firr sale (Scc.7044. Busincss and Prolcssions Cotle: Thc Contraclor's l.iccnsc Law does not apply to an owltcr of <br />thc pnlpcrty who huilds or inlprovcs thercon. and who docs such work hirnsclf or hcrsclf or through his or hcr own enrployecs. <br />providcd that such inrprovcnrnts arc not intcrxlcd orollbrcd ftrr sah. ll. txrwcver. thc buikling or inrprovernnl is sold within onc ycar <br />of cornphtion. tlrc Owncr Buiklcr will have thc burdcn of proving that hc or she did mrt huih or improvc thc propcrty for thc purJxtsc of <br />salc). <br />_1. as owner ol'thc propcrty. am exclusively contracting with liccnsctl conlraclors to construct lhc projcct (Scc. 7(X4. Busincss <br />arxl ftrrfcssion Codc: Thc Contraclor's Liccnsc Law docs not apply lo iln owner of propcrty who huilds or improves thcrcon. <br />and who contracts for such projccts with a Contraclor(s) liccnscd pursuant to thc C<lntractor's Liccnse Law). <br />-latncxemptundcrScction-.B.&P.C.ftlrthisrcason. <br />I)ale:( )rr ner: <br />WORKT.]RS' COt\I IDDNSA'I'I()N <br />DFCI,A IIA'I'I0N <br />I hcrcby aftlrnr undcr pcnalty ol'pcrjury onc ol'thc followirrg dcclaratiotts: <br />_lhavcandwill maintainaCcrtificateofConscnttoScll'-lnsureforworkcrs'compcnsation.as providcdforbySection3T(Dofthc <br />Lrbor Codc. forthc perfornrance of the work firr which thc pcrntit is issucd. <br />_l havc and will maintain workcrs'compcnsation insurancc. as re<luircd hy Scclion 3700 of thc Lrbor Codc. for the Jrcrformance of <br />lhc work for which this perrnit is issucd. My workcrs' conrJrcnsation insurancc carricr und Jrolicy nunrtrcr are: <br />Carricr: <br />Policy Number: Expires: <br />_l ccrtify that in thc perfornunce of thc work for which this perrnit is issucd. I shall not employ any pcrson in any manncr <br />so as to bcconrc suhjcct to lhe workers' cornpcnsation laws ol'Calilbrnia. and agrcc thal if I should hcc<lmc subjcct lo the <br />workcrs' comJrcnsation provisions of Section 3700 of thc l;rtnr Codc, I shall. forthwith comply with those provisions. <br />WARNING: Failurc to sccurc workcrs' cornpcnsation co!'cragc is unlawful. and shall subject an cntploycr to crirninal Jrcnalties and <br />civil lincs up lo onc hundrcd lhousand dollars ($1fi).(XX)). in lo the cost of compensation. danrages as providcd for the <br />allorncy's l'ccs. <br />I hcrchy affirrn undcr pcnalty of pcrjury that I artt liccnscd uttdcr provisiolt 9 (corrurcncirrg with Scction 70m) of Division 3 <br />of thc Business and Professiclns Code. antl nry liccnsc is in t'ull forcc atxlclfect. <br />Liccnsc <br />Date: <br />CONSTRUCTION LENDING AGENCY <br />I hcrcby atfirm undcr JEnalry of lErjury that thcrc is a conslruct ion hndirg agency l'or lhe Isformncc of thc work for which lhis lErmil ls <br />issucd (Scc. 3097. Civ. C.). <br />lrnder's Name: <br />I-crttlcr's Addrcss: <br />APPI IC ANT DECLART{TI(TN <br />I hcrcby allimr undcr penalty of pcrjury one of lhc following declaratiotts: <br />Dcmolition Pcrmits-Asbcstos Notification Fcdcral Regulations (Titlc 40. Part6) <br />-Rcquircd <br />Lcttcr of Notification <br />_l ccrtify that thc t'cderal rcgulalions rcgarditrg asbcslos rcrnoval arc rrol applicahlc lo this projcct. <br />_l certify thal I havc rcad this application and slatc thll lhc atnvc infrrnrtitliort is corrcct. I agrcc to contply <br />reprcscntativcs of this City <br />with all City and County <br />and County lo cnter upon thcordinanccs and Statc [.aws relating to <br />abovc nrntioncd propcrty for <br />Applicanl or Agenl <br />I'entrilee nanre ( ;lrirtt ): <br />and hcrehy tulhorizc <br />,rr",4% <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenVI nsu lation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulatio nlEnergy <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 />Engineer Fina! Report <br />Flood Zone Certif . <br />I <br />FINAL tlnlat Arld 7n <br />Certificate of <br />Notes, Remarks, Etc.t <br />Scctiorr 3076 of thc Latnr Codc. <br />"",", q/4_//q <br />t) <br />i(lontractor: