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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION <br />I hqcw affm unds pcoahy of pqjury that I m qmpt from thc Contrac{oF' LiccE Lrw for thc following tten (Ss.7031.5 <br />Buinas md Prcf*ion Codc): Any City or County which rcquim a pamil to coNtruct, alto, improvc rkrnolish or rcpair iny <br />strucluq prior lo its isuucc. also rcquirG thc applicut for such pennit to filc a signcd statoot thal hc or shc b liccnscd ptmEtl( <br />to thc povisio$ of thc Clntractor's Liccnsd law (Chapts 9. Commcing with Setioo 7000 of Division 3 of thc B$ins {d <br />PrcfcsionsCodc)orthathcorsheiscxmptthqcfromodtheb8isforthealleg€dq@Fion. AnyviolalionofSdtionT03l.5byany <br />applicdt fo. a pcrmit subjcts thc applicant to a civil pcnalty of not more thil fivc hun&cd dollffi ($500). <br />_1. as owner of the property. or my cmployecs with wages as their sole compensation. will do the work and the structure is not <br />intended or offered for sale (Sec.7044. Business and hofcssions Code: The Contractor's Lice'nse law does not apply to an owncr of <br />the properry who builds or improves thereon, and who docs zuch work himself or hersclf or through his or her own employec. <br />providd that such improvancnts arc not intended or oflA'od for salc. If. however. the building or improvernent is sold within one )car <br />of complaion the Orvner Buildcr will have the burden of proving that he or she diJ not build or improve the propcrty for thc purposc of <br />sale). <br />_1. as owner of the property. am exclusively contracting with licensed contraclors to construct the project (Scc. 7044. Bwiness <br />and hofession Code: The Contractor's Licensc Law does not apply to an owner of property who builds or improves thereon. <br />and who contracts for such projects with a Contraclo(s) licaued pursuant to the Contractor's Licensc l-aw). <br />-l <br />am e.\empt under Scction---. B. & P.C. for this reason. <br />l)alc <br />WO RI(E R,S' COMPEN SATION <br />DECLARATION <br />I hereby affrrm under penalty of perjury one of the following declarations: <br />_l have and will maintain a Certificate of Consent to Self-lnsure for workers' compensation. as provided for by Scction -3700 of the <br />Labor Code. <br />/, nur. urroG work for <br />for the perfonnancc of the work for which the perrnit is issued. <br />Section 3700 of the Labor Code. for thc pcrfonnance of <br />,carrier and policy number are: <br />Policy t\L <br />-l <br />ccniry that in thc pcrfomancc of thc work for which this pcrmit is issucd, I shall not mploy any pcrson in oy mona <br />m utobeomesubjcttothercrk6'ompersationlawsofCalifomia,edagrcthatiflshouldbeomesubjattothc <br />rcrk6' comperution prcvisiou of Serion 3700 of the Labor Codc, I slu.ll. forthwith comply with thos prcvisiorc. <br />WARNINC: Failurc to suc mrkm' comperstion covmgc is unlawful, ad shall subjat m aploF to qiminal pquhiB ild <br />civil fincs up to onc hundrcd thousd doll6 ($100,000). in addition to the cost of compcrution. damg6 s providcd for the <br />Section 3076 of the labor Code. interest and attorney's fecs. <br />I 11 <br />I hereby allirm under penalty of perjury that I am licensed 9 (commencing with Section 7000) of Division.l <br />of the Business and Professions Code. and my license is in full force and effect. <br />License <br />Date: <br />Number:E5 <br />ctlloil 'Ll t1r----f <br />W <br />I hcrcby aflirm undo pcnalty of pqjury that thqc is a @Ntruction loding agocy for thc psfomucc of thc work for which lhis pqnil b <br />issucd (Se. 3097, Civ. C.). <br />Lender's Name: <br />Lender's Address: <br />AEUCANIDECI.ABAIION <br />I ho@afirm undo poalty of pcjury onc of thc followitrg delsntios: <br />Dcmolition PmitsAsbetos Notifrcstion Fcd@l Rcgulatios (Titlc 40, Pan6) <br />-Rcquircd <br />trtta of Notificarbtr <br />_l cqriry rhar thc fcddal rcaulatiom rcgrding cbcros moval e not applicablc to thie proj6{. <br />ftft "rttty t* t t nc rad this application 8d ststc thar rhc abovc informaion is conet. I agre to comply with all City ud Couty <br />ordiruc6 ed Statc law rclalg to building construction, atd h@by suthorire rcprenativc of rhis City ud Couty to mtq upotr thr <br />above mentioned property for inspection <br />Applicant or Agent <br />Permitee name <br />Set Backs <br />Forms/Stee!/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bfloor/Ve nUl n s u I atio n <br />Roof Sheathing <br />Shear Wall <br />Framing <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif. <br />F!NAL <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />i'w <br />5 <br />,,,", O gfttlf L(