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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER, DELCARATION <br />I hcrcby atlirm undcr penalty of lcrjury that I am cxcmpt l'rum thc G)ntractos' Liccnsc llw titr thc lirlklwing rcasm (Scc.70J 1.5 <br />llusincss anl Prolbssion Gxlc): Any City or County which rcquircs d lEmit lo construct. allr. improve. dcmolish or rcIair any <br />slructurc, prirr to its issuancc, also rcquircs lhc applicant l(rr such ,Ermit k) filc I sigrcd statemnt that hc or shc is liccnsd pursuant <br />k) thc provNi(rns of tlrc Contrack)r's Liccnscd Law (Chaplcr 9, Commncilg wilh Selion 70OO of Division ,l of thc Busincss and <br />Pr)fcssi(rns C(rdc) or that hc or rhc is cxcmpt thschom atrd thc hasis for thc allcgcd cxcmption, Any violalion of Setbn 703 I .5 by any <br />opplicant for 0 pcrmit suhjets thc applicanl k) a civil pcnally of nol mrrc than livc hundrcd dollors ($5m). <br />_1, as owncr of thc propcrty, or my cmployccs wilh wagcs as thcir solc comlrcnsation, will do thc work and the slructtrc is nol <br />intcndcd or oll'crcd lilr sale (Sc'c.7044, Busincss and Prot'cssions Crxlc: Thc Contractor's Liccnsc Law docs not apply to an owncr of <br />thc pnrJx:rty who builtls or inrprcvcs thcrcrrn. and who drrcs such work himscll'or hcrsclf or through his rlr her own cmpkryccs, <br />provir.lctl that such improvcrncnts a.rc mrt intcndctl or oltbrcd lirr salc. li howcvcr, thc building or inrprovcrncnt is sokl within onc yciu <br />ol'complction, tlrc Owncr Buiklcr will turvc tlrc burdcn o[proving that lrc or shc did rxrt buikl or impnrvc thc prupeny lbr thc pur;xrsc of <br />salc). <br />_1, as owncr <ll'thc pn)Frty, am exclusivcly contracting with liccnscd contractors lo construct thc pnljcct (Scc. 7M4, Busirtcss <br />and ['nrlbsskrn Codc: 'l'lrc Contractor's Liccnsc Law docs not apply to an owner ol'propcrty who huilds or improvcs lhcrcon, <br />and who contracts lirr such projccts with a Contractor(s) liccnsctl pursuant to thc s Liccnsc l-aw). <br />_l am cxcmpt u.&P <br />I hcrcby atfirm undcr pcnalty of Jrcrjury onc of thc tirlktwing <br />_l havc and will maintain a Ccrtilicatc of Consent to Sclt-lrrsurc lilr workcrs' compensation, as providcd tirr by Sectiort -3700 of thc <br />L-atxlr Crxlc, lilr thc Jrcrlbrmancc of thc work lilr which thc 5rcrmit Ls issucd. <br />_l havc and will maintain workcrs' comJrcnsatiorr insurancc, as rcrluired by Scct ion 3700 of thc Labor Code, tirr the Jrcrlirrmancc of <br />thc work for which this Jrcrmit is issucrl. My workcrs' compcnsation insurancc carricr anl Jxllicy numbcr are: <br />t <br />Policy Numbcr: Expircs: <br />_l ccrtily that in thc pcrlirrmancc of thc work tirr which this perrnit is issucd, I shall not cmpkry any lrcrson in any manncr <br />so as to hccomc suhjcct to thc workers' comJrcnsatiorr laws of Califirrrria, and agrcc that if I should hcconrc subject to tlrc 7r <br />wrlrkcrs' comJrcnsation provisions of Scction 17fi) of thc Lrhrr Crxlc, I shall. tilrthwith comply with thosc provisions. <br />WARNING: I.ailurc to sccurc wrlrkcrs' compcnsation covcragc is unlawtirl, and shall suhjcct an cmpkrycr to crimhal Jrcnaltics and <br />civil line-s up lo onc hundrcd thottsand rftrllars in atldition of damages as providcd lirr thc <br />Section 3QQ rtf the Latxlr Grdc, intcrcst and <br />Date: <br />I hcrchy atlrm undcr pcnalty of Jrcrjury thal I am liccnscrJ 9 (commcncing with Scction 7firu) of Division J <br />ol' lhc Busincss and l'nlt'cssiorrs Crlrlc, ail my liccnsc is in lull lirrcc and <br />Licensc Class: Liccnsc Numbcr: <br />CONSTRUCTION LENDING AGENCY <br />I hcrcby BfFrm undcr Fnalty of ltrjury thst thcrc is . construction lcrxling agcrcy for thc lrcIfomrec of lhc wrk fur wtich this tmit is <br />issucd (S@. J(x)7, Civ. C.). <br />[.nlcr's Namc: <br />[-cndcr's Addrcss: <br />APPLICANT DECLARATION <br />I hrchy atlirm undcr pcnalty of Srcrjury one of thc folkrwing dcclarations: <br />Dcmolition Permits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40, Part6) <br />_Rcquircd lrttcr of Notilication <br />@deralrcgulatitlnsregardingasbcstosrcmoval&rcn()tapplicatrlctothisprrljcct. <br />_l ccrtily that I havc rc.ad this application aml statc that thc ahlvc intilrmaliorr is correct. I agrcc to comply with all City and County <br />ordinanccs and Statc Laws relating to <br />atxlvc mcntioncd proJrcrty lilr <br />Applicant or Agent <br />and hereby rcprcscntativcs of this City and County to enter uJxrn thc <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenUI ns u lation <br />Roof Sheathing <br />Shear Wall <br />Framinq €-t 3-21 I ELnt rl, <br />lnsu lation/Enerqy <br />Drywall <br />Ext./lnt. Lath q -2- L\l*rA-t rl. <br />Brown Coat q-lS-.?zt <br />-,nf <br />Clr <br />[\Iasonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif. <br />FINAL t-t S-Zr <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />It--a^.