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BUILDING- INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DEI,CARATION <br />I hcrcby allirm undcr pcnalty of Jrrjury that I am cxcmpt ln)m lhc G)nlraclors' Liccnsc tlw for thc lbllowing rcasu\Se.7031.5 <br />Busincss arkl Profcssi(rn C(xlc): Any City or County which rcquircs a lEmit k) construct, altcr, improvc. dcmlEh or rcpair any <br />slruclw, [trk r t, ils issuarLt, als(t rcquircs thc applicant lbr such ]Emil to tilc a si8ncd stalcmnt that hc or shc is liccnsd pur$tst <br />k) lhc prlvisions of thc C(rnlraclor's Liccnsd hw (Chaptcr 9, Commcreing with Sccti(rn 7000 of Division .] of thc Busincss and <br />P(rfcssionsC(rdc)orlhatlEorshciscxcmptlhcrcliom.trdthcbasislirrthcallcgcr.lexcmplion. Anyvi()laliqrofseti()n70.ll.5byany <br />applicant li)r a lrcmit subjccts thc applicnnt to a civil pcnally of nol morc thtn livc hundrcd dollars ($500), <br />_1, as owncr of'thc propcrty, or my cmployecs with wages as lheir sole compcnsation. will do the work afiJ the slructurc is nol <br />intcndcd or oll'crcd lirr salc (Scc.7(X4, Busincss and Profbssions Crilc: Thc Contractor's Liccnsc Law does not apply to an uwncr of <br />thc pnrJnrty who builds rlr impnrvcs thcrcon, artd who drrcs such work himsclf or hcrsclf rlr through his or hcr own cmphyccs, <br />providcd that such impr<lvcn**nts arc xrl inlcndctl or oll'crcd lirr salc. Il, howcvcr, thc building or imprcvcrncnt is sold within onc ycar <br />ol'comphtion, thc Owncr Buildcr will havc thc burrlcn ol'proving that hc or shc did rxrt build or impnrvc thc propcrty lirr thc purprsc ol' <br />salc), <br />-1, <br />as owner of the property, am cxclusivcly contracting with liccnscd contractors to constntct lhc projcct (Sec. 7M4, Busincss <br />and Prulbsskrn Codc: The Contraclor's Liccnsc Law docs nol apply to an owner of prcJrcrty who builds or improvcs lhcrcon, <br />and who contracts lilr such prtrjccts with a Contractor(s) liccnsctl pursuant to lhc Conlractor's Liccnsc Law). <br />-IamcxcmptundcrScctirln-'B.&P.C.tirrthisrcastrn. <br />fl.'Ia. <br />]UABtsEESSAIIEENSIIONpsc!,AMgoN <br />I hcreby allirm undcr Fmlty oflErjuryonc oflhc f(rllowing dcclarations: <br />idl havc arl will maintaio a Ccdil-rcalc of Consnt to Sclf-lnsurc li)r workcrs' comlrcusation, as prcvidcd for by Scction .!?fi) of thc* Labor Gxlc, for thc JErformrEc of thc work f(rr which thc Jrcrmil i{ issucd. <br />{$ havc an.t will maintain workcrs' compcmation insurancc, as rcquircd by Scction .17fi) of lhc L{bor Gilc, tor thc pcili}mancc of <br />thc work lilr which this 1rcmit is issucd. My xrrkcrs' com;rcnsation insurancc caricr anl Fllicy numbcr ec: <br />()\T\\ <br />tr 2l t <br />tlrat in thc pcrtirrnrancc of thc work lirr which this pcrrnit is issucd, I shall rxrl cnrpkly any pcrs()n in any manncr <br />so as to bccomc subjcct to thc workcrs' compcnsation laws of California, and agrcc that if I slxluld bccome subject to thc <br />wrlrkcrs' compcnsation pnrvisions of Section 37fi) of thc Lahlr Crilc, I shall, tirrthwith comply with thosc pnrvisions. <br />WARNING: Failurc lo sccurc workcrs' com;rcnsation covcragc is unlawl'ul, and shall subjccl an cmploycr to criminal pcnaltics and <br />civil lirrcs up to onc hundrcd thousantl dollars ($lffi.fiXtt, in additi<ln to thc cost of compcnsalion, rlamagcs as providcd ftlr thc <br />Scction .1076 of thc l-ahlr Crxlc, intcrcst and attrlrncy's t'ccs. <br />'2 <br />I hcrcby allirnt urrrler pcnalty ol'1-*rjury l <br />rtl' thc lJusirtcss and Prol'csskrns Codc, and my liccnsc is in f'ull tirrcc ard cflbct. <br />Liccnsc crurr, 9 Licensc Numbcr:4v7Zq,L1 <br />I\.. t ^.I HL ?ro'{G5\<;nc\\ Bqt Ur}1 <br />W <br />I hcrcby off[m undcr lEnalty of Fsjury that therc is a constructhn hndirg agcNy for the JErformree of thc work for which this Ismit is <br />issucd (Scc. 3097, Civ. C.). <br />[4Blcr's Namc: <br />Lctttlcr's Adtlrcss: <br />APPLICANT DECLARATION <br />I lrcrcby allirm undcr Jrcnalty of Jrcrjury onc of thc lirlkrwing tlcclarations: <br />Dcnxrlition Permits-Asbestos Notification Federal Rcgulations (Titlc 40, Part6) <br />_Rcqu rcd lrtter ol' Notilication <br />-l <br />ccrtify that the lcdcral rcgulations rcgddinS asbcstos rcmrval arc not applicablc ft) this p()jet. <br />r.-lJ <br />\zLI lcnily that I havc rcad this application aBl statc that thc alxlvc inli,rmtkrn is corcct. I agrc to comply with all Cily and County <br />ordhamcs nftl Statc hws rclaling to huilding construction, firl hcrcby authorize rcFcsntatives ofthi$ City anl County to cntcr uFrn tlr <br />atxrvc mcnlioncd propcrty tbr purF)scs. <br />Ua-tc-tu lz(Applicant or Agerrt I,a <br />Pcmilemmc(prino, t-rnct t-llcltvrct <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bf Ioor/Ve nVI nsu lation <br />Roof Sheathinq <br />Shear Wall <br />Framing <br />Insulatio nlEnerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Jt/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif . <br />I a9r ) <br />FINAL lpltfilz;r (T <br />Certificate of Occupancv rI t () <br />Notes, Remarks, Etc. <br />Elarr nP.-n7 -2n 1 q <br />a <br />| 1r6,a1f if .