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BU!LDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG COMMENTS OWNERBUILDERDELCARATION \ I hcrcby ailfum undcr lEnalty of lrcrjury that I am crcmpl from thc G)ntrackrn' Lfucnsc Law for tl#luwing riasrn (Scc.7031.5 Busincss arrl Profcssion C<xlc): Any City or County which rcquircs a ;rrmit k) conslruct, allci improvc. dcm(tlish rrr rcpair {ny slruclurc. pri(rr to its issuancc, alm rcquircs thc applicant for such lEmit to tilc a signcd statcmnl thrt hc or she is liccnsd Pusuant to tlrc pruvisiotrs of thc Contractor's Liccnsd llw (Chaptcr 9, Commcrcing wilh Sstion 70ffi of Division -l of thc Busircss and PnrlbssionsColc)(nthatlEorshciscxempllhcrcfromandthchasisfirrthcallcgcdercmption. Anyvi(rlatttnofsetionTofl.5byany applicant tbr a JErmit subjccts the applicant k, . civil pcnalty of not mtrc than fivc hundred dollus (Ssfi)), _1. as owncr of tlrc propcrty, or my cmployccs wilh wagcs as thcir solc compcnsalion, will do thc work and thc stru,cturc is not intcrrrJcd or ol'fcrcd tirr salc (Sc'c.7M4, Busincss and Pnrt'cssions Cmlc: Thc Contractor's Liccnsc [-aw dtrcs not apply to an owner of thc pnlJrcrty who builds or improvcs thcrcon, and who drrcs such work himsclf rlr hcrself or through his or hcr own cmployccs, provided that such impnrvcnrcnls arc not intcndcd or ollbrcd lirr salc. It, however, tlrc building or impr)vcnrcnt is sokJ within onc ycar ol'comphtkrn, thc Owncr Buikicr will have thc burdcn ol'proving that hc or shc did not buihl or improve the pntJrcfly firr thc purJxtsc o[ salc). _1. asowncrof thc proF-rty, amexclusivclycontracting with liccnsed contraclorstoconstruct thc pnljcct (Scc.7044, Busincss and holbssion Codc: Thc Contractor's Liccnsc Law docs not apply to an owncr of prolrcrty who builds or improvcs thercon, and who contracts tbr such projccts with a Contractor(s) liccnscd pursuant to thc Contractor's Liccnsc [aw). -IamcxcmptundcrScctirln-,B.&P.C.tilrthisreastln. }VORKERS' CONI I'I,NSATION DECLARATION I hcrcby atTirm undcr Fnalty of pcrjury onc of thc lirlkrwing dcclarations: _l havc arxl will maintain a Ccrtilicatc of Conscnt to Sclt'-lnsurc tbr workcrs' compcnsation, as providcd for by Section 3700 of thc latxrr CuJc, for thc Jrcrlbrmancc of thc work lilr which the ;rcrmit ls issucd. _l have and will maintain workcrs' compcnsation insurancc, as requircd by Scction .17fi) of thc Labor CuJc, ftrr thc Srcrtilrmancc of thc work lilr which this permit is issucrJ. My workers' compcnsation insurance carricr arxl Jxllicy numbcr arc: Policy Numher: Expircs: _l ccrtily that in thc pcrlirrmancc ol'the wrlrk tor which this Jrcrmit is issucrl, I shall not empkly any pcrson in any manncr . so as to bccomc subjcct to thc workcrs' compcnsation laws of Calitbrnia, and agrcc that if I should hccomc subjcct to thc workcrs' comgrcnsation pr<lvisions ol'Section 37ffi of thc [:hrr Crxlc, I shall, tirrthwith comply with tlxrsc provisions. WARNING: Failurc to sccurc workcrs'comJrcnsation covcragc is unlawful, and shall subjcct an employcr to crinrinal pcnaltics and civil lincs up to ()nc huntlrcd thousand dollars ($100,000), in addition to thc cost of comlrcnsalion. damagcs as providcd tbr thc Scction 3076 of thc Labor Crxle, intcrcst and attorncy's l'ccs. Date: Applicantl LICENSED CONTRACTOR DECLARATION I hcrcby atlirm undcr pcnalty of pcrjury that I am liccnrcd undcr provision of Chaptcr 9 (commcncing with Scction 7fiX)) of Division 3 of the Busincss and Professions Ctxlc, arxl my licensc is in full forcc uxl effcct. Liccnse Class: Liccnse Numbcr: Contractor: W I hcrcby allirm undcr JEnalty of Frjury that rh@ is a c$nstruction hnding agcrey for thc lErfomnce of lhc sork lirr which this tsmit is issucd (Se. 3U)7, Civ. C.). kntler's Nanrc: I-cndcr's Address: APPLTCANT DECLARATION I lrcrcby allirm undcr Fnalty ot'pcrjury one of thc folkrwing dcclarations: Dcmolition Pcrmits-Asbestos Notification Fcdcral Rcgulations (Titlc 40, Part6) _Rcquircd l,cttcr of Notitication _l ccrtily that the fcdcralrcgulations rcgarding ashcstos removal arc not applicablc to this projcct. _l ccrtity that I havc rcad rhis .pplicatbn dxl statc that tlrc ah)rc information is corcct. I atre k) $mply with all Cityand County ordinarecs and Statc hws rchting to huilding construclion, atx.l hcrcbyaullf,rrizc rcFesntntivcs ofthis City and County to cntcr u[x)D thc atxlvc rentioncd prolrcny for inslrcction puli)scs. Applicant or Agent Signature:I)ate: Pcmite mmâ‚¬ (prinl): Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/Ve nVl ns u latio n /) Roof Sheathins }..ro Jh ec*qwo,, 16llu c*t* bo+W Shear Wall I Framing lnsu lation/Energy Drywall Ext./lnt. Lath Brown Coat Jt/asonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif lt FINAL tgl'lgl-A Dk+E7 Certificate of Occupancy Notes, Remarks, Etc. Florr ^9,-fi79nl q