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BUILDING- INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby alfrrm undcr pcnalty of Jrcrjury that I am crcmpt from thc ContrackrB' Liccn* law for thc lbllowing rcasrn (Soc.7031.5 <br />Busilcss arxl Profcssiotr Cdle): Any City or County which rcquircs a lErmit kr conslruct. oltcr. improvc, dcmolish or rcpait ,ny <br />structurc, ltrDr to ils issuscc, als rcquircs thc spJrlicsnt for such lrcrmit k] tile a signcd statcmnl lhat he or slE is liccnsd pmuant <br />b thc lmvisions of thc Contractor's Licenscd Law (Chaptcr 9, Comcreing with Scction 7(XX) of Divishn 3 of thc Busircss afil <br />ProtbssionsCodc)orthathcorsheisexemptthcrcfromandthebasisforthcalle8cdcxcmption. AnyvttlationofscctionTOJI.5byany <br />applicatrt for I |rcmit subjets the applicant to a civil pcmlly of trol m(rrc than livc hundrcd dollus ($5(x)). <br />_1. as owncr of thc propcrty, or my employccs with wagcs as thcir solc compcnsation, will do lhc work aml thc shw*ture is not <br />rntcndcd or ollercd lirr sale (Sec.7M4, Business and Prot'cssions Crxle: Thc Contractor's Liccnsc L:w drrcs not apply to an owner of <br />thc pnrpcrty who builds or improves thcrcrrn, arxl wtxl tlocs such work himsclf or hcrsclf or thnrugh his or hcr own employccs, <br />providcd that such improvcnrcnts are not intcndcd or ofl'crcrl for salc. If. txlwcvcr, thc buikling or improvcnrcnt is s<lkl within onc ycar <br />ol'comphtion, thc Owncr Buikler will have thc burdcn of proving that hc or shc dll not buikl or inrprovc thc pnrJrrty for thc puryxrsc of <br />salc). <br />_1, as owncr of the property, am exclusively contracting with liccnscd contracton lo construct thc pnlject (Scc. 7OM, Busincss <br />arxl Pnlfesskrn Crilc: Thc Contractor's Licensc Law docs not apply to an owncr of proJrcrty who builds or improvcs thcrcon, <br />and who conlracts for such projects with a Contractor(s) liccnscr-l pursusnt to lhc Contractor's Licensc kw). <br />-IamcxcmptundcrScction-.B.&P.C'ftlrthisrcastltl. <br />Date: <br />W ORKERS' COIII PENSATION <br />Ihcrcbyat1rrmuntlcrpcnaltytlfpcrjurytlneofthe,u,u,*"*ffi <br />_l havc and will maintain a Ccrtilicate of Conscnt to Sclf-lnsurc firr workcrs' comJrcnsation, as providcd tbr by Scction 3700 of thc <br />l-atxlr Culc, lor thc pcrformancc of the work for which the Jrcrmit is issucd. <br />[t nur" and will maintain workers'compcnsation insurance, as rcquired by Scction 3700 of thc Labor Ctxle, tirr thc Jrcrlbrmance of <br />thc work tbr which this pcrmit is issued. My workcrs' compensation insurancc carricr and Jxrlicy number arc: <br />CrBFrrn-t1 <br />poricyNurnt"r'(dfia- 6q(9-tt\SfZ?- o?o Expircs: tc, /", / Z I <br />_l ccrtity that in thc Jrcrtirrmance of the work tilr which this Jrcrmit is issucd, I shall not cmphry any lrcrson in any manncr <br />so as to r-kct)mc suhjcct to thc workcrs'comSrcnsation laws of Calitbrnia, and agrcc that il'l shoukl hecomc subjcct to the <br />workcrs' comJrcnsation pmvisions of Scction 3700 of thc Lahrr GxIc, I shall, tirrthwith comply with thosc pnlvisions. <br />WARNING: Failurc to sccurc workcrs'comJrcnsation covcragc is unlawful, and shall subjcct an cmpklyer to criminal pcnaltics and <br />civil lincs up to onc hurrdred thousand dollars ($100,firu), in addition to thc cost of compcnsation, damagcs as providcd for lhc <br />Scction 3076 of thc Labor C<xle, intercst and attonrcy's fccs. <br />LICENSED CONTRACTOR <br />DECLARATION <br />I hercby allrm under pcnalty of prjury that I am Licensed undcr pnlvision of Chaptcr 9 (commcncing with Scction 7UX)) of Division 3 <br />ol' thc Busrncss and Prol'essions Code, arxl my liccnsc is in l'ull lirrcc aml ctl'cct. <br />Liccnscglu"..C'to C-L( (, LiccnscNumhcr: n5C) t g\ <br />(o o ZL Conlr;rclnr'(-lr..J fav^/ <br />CONSTRUCTION LENDTNG AGENCY <br />I hcrcby affrm undcr grcnalty of fsjury lhal thcrc is a conslructi)n hnding agcrey for thc lErforrorec of thc wotk for which this Imit is <br />issucd (Scc. 3097, Civ. C.). <br />[-cndcr's Name: <br />APPLICANT DECLARATION <br />I hcrcby all'rm undcr pcnalty of ;rcrjury one of thc lirlklwing dcclarations: <br />Dcmolition Pcrmits-Asbcstos Notitication Federal Rcgulations (Titlc 40, Paa6) <br />_Rcquircd l-ctter of Notitication <br />_l ccrtily that thc t'cdcral rcgulations rcgarding asbcslos rcnxrval arc not applicahlc to this pro.jcct. <br />A I ccrtity thar I have rcad this application and state that thc atxrvc inlirrmation is corrcct. I agrce to cttmply <br />ordinanccs and Statc Laws relating to building construction, and hcrchy autlxlrizc rcprcscntativcs <tf this City <br />with all City and County <br />and County to entcr uJxrn thc <br />z(q l.t <br />l)cnrritee nanle <br />g,rv/ <br />Set Backs <br />Forms/Stee!/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bf loor/Ve nVl ns u lation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />!nsu lation/Energy <br />Drvwal! <br />Ext./lnt. Lath <br />Brown Coat <br />Masonrv <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />FINAL <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />Flarr nP.n7 3n1q <br />,rr.' ?-l V I Z t Annlicanl: <br />ahovc- nrcntioncd prcpcrty lilr <br />Applicant or Agenl <br />lrrrirrll.BG.muocr.r DfetFS <br />t\--.^-