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INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNF'R RUILDTR DFI CARATION IherebyaffrrnrunderpenaltyofperluwthatlanrexenlptfornrtheContractors'LicenseLawforthefollowingreason(Sec.703l5Busrness and Professron Code) Any City or County whrch requrres a permil to construct. alter. rnrprove. demolish or repatr 8ny struclure. pnor to tts issuance. also requires the applicant for such pernrrt to file a srgned statement that he or she is licensed pursuant to the ptovtstons of the Contractor's Licensed Law (Chapter 9. Conrntencing wrth Section 7000 of Division ,1 of the Business and Professrons Code) or tltat he or shersexenrpttherefronrandthebasrsfortheallegedexenrptron AnvvrolatronofSectionT03l 5byanyapphcantforapermtlsubfectsthe applicant to a crvil penaltv of not more than fir'e hundred dollars ($500) [1. ,= owner of the property. or my enrployees wrth wages as tlrerr sole compensatton. wrll do the work and the sffuctttre rs not tntended or olTered for sale (Sec 704.{, Buslness and hofessrons ('ode The Contraclor's l,rcense Larv does not apply to an o\\Ter of the property who burlds or rnlproves thereon. and rvfto does such uork himself or herself or through his or her own entployees, provrded that strch improvemens are not intended or offered for sale. If, however, tre buildrng or improvemenl is sold wrtrin one year of completron. tre Owner Builder will have the burden of proving that he or she did not burld or improve dre propero for tlre purpose of sale) E.* owner of the progrcrty. am exclusrvely contracting wrth lrcensed contractors to construct the pro;ect (Sec 7M.1. Bustness and Professlon Code The ('ontractor's l-rcense l-arv does not apply to an owner of property who bullds or tmproves lhereon. and who contracts for such pro;ects Mth a Contractor(s) licensed pursuant lo the Contractor's Llcense Law) No t rrn exempr under Sectron . B & P.C. for this reason \UORKERS' COM PENSATION DTCLARATION I hereby affirnr under penalty of per.lury'one of the followrng declaratrons: rc I h"r. and wrtl nrarntarn a Cerrificate of Consenr ro Self-lnsure for uorkers' conrpensalron. as provtded for by Sectton 3700 of the Latnr Code. for the performance of the work for u/rich the permrt ts tssued. YES _l have and rxrll marntarn u'orkers' compensafion rnsurance. as requrred by Sectron 3700 of the Labor Code, for the performance of the work for r,r,lrrch this permrt rs rssued My workers' conpensalron rnsurance carner and polrcy number are ('arrrer State Fund ItrlllTto Pohcy Number. Exptres 0at01t2022 NO _l certifo that rn the performance of the work for which thrs pernut rs rssued. I shall not employ anv person tn any manner so as to beconre sublect to the workers'compensation laws of ('alifomra. and agree that rf I should beconte subject to the workers' compensatton provisions of Sectron .l700 of the Labor Code. I shall. forthwrth comply witlr those provtstons WARNING Farlure to secure workers' conrpensatton coverage is unlawful. and shall sublect an emplover to cnmtnal penaltres and crvil fines up to one hundred tlrousand dollars ($100,000), rn addrtron to the cost of compensatron, damages as provlded for the Sectron 3076 of the Labor Code. interest and attomev's fees LI('TNSED CONTRACTOR NECLARATION I hereby affrrnr under penalty of per1ury that I am hcensed under provrsron of Chapter 9 (conrnrcnctng wtth Section 7000) of Drvrslon .l of the Busrness and Professrons Code. and nry license is rn full force and effect c39 Lrcense Class l,rcense Nunrber 75E51 I CONSTRI.'C-TION I FNDING AGENCY I herebv aftirm under penalty of per1ury that there rs a consln.ction lendrng agency for the performance of the work for whrch thts permtt ts issued (Sec 3097. Civ C ) l-ender's Nanre Lender's Address: APPLICAI\T DECT ^ RATION I hereby affimr under penalty of perjury one of the followrng declarations Demolition Pernrits-Asbestos Notrfication Federal Regulalrons (Title 40. Part6) rc Requrred Lenerof Notrficauon YEg f cerliry that the federal regularions regarding asbestos removal are not apptrcable to this ploJect. E | ..rt,fo thar I have read thrs apphcatrcn and stare that the above rnfornration is correcl I agree to conrpty with all Crtv and Cotnty ordinances and State Laws relatrng to burlding constructmn. and hereby authorze represenlauves of this Crty and County to enter upon the above nlentioned properw for inspeclron purposes Reroof Roof (Diaphragm Sheathing/Frame)/o/gz Z( TTZ 7 Structural Final telzut >LN +ffi Plumbing I I Under Floor I Under Slab Rough Shower Pan / Tub Test Water Service Sewer / Sewer Cap Gas Air Pressure Test Plumbing Final Electrical Service (Meter / Panel) Grounding / Bonding Rough Electrical Final Mechanical Gas Air Pressure Test Rough Piping (HW, CW, etc.) Exhaust Ducts Mechanical Final Notes, Remarks, Etc.