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BUILDING. INSPECTOR RECORD ID/SIG.COMMENTSSITE.WORK DATE Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf Ioor/VenVl nsu lation Roof Sheathinq Shear Wall Framinq lnsu latio nlEnerqy Drywall Ext./lnt. Lath Brown Coat [\Iasonry Pool Fence T-Bar Handicap Req. Deoutv Fina! Report Enqineer Final Report Flood Zone Certif oI -r tl , FINAL rfl \nK V,\ftNI -/ Certificate of Occupancv \r Notes, Remarks, Etc \ \ OWNER BUILDER DELCARATION I hcrchy aflirm undcr JEmlly of pcrjury that I dtr crcmpt fmm thc ContractoN' Liccnsc law for thc following rcasn (Scc.7031.5 Busincss and Profcssion Codc): Any City or County which rcquircs a pemir to construct. altcn impmvc. dcmlish or Epair any sIruclurc, prior lo ils issuarcc, also rcquircs thc applicant for such lErmit to filc a signcd statemnt thal hc or shc ir liccnsd pusant ro lhc pmvisions of thc Contractor's Liccnscd law (Chaptcr 9, Comncing with Sation 7000 of Division 3 of thc Busircss and PrcfcssionsCodc)orthathcorshciscxcmptthncfromandthctxlsisforthcsllcgcdexcmption. AnyviolationofscclionT03l.5byany opplicanl for I pcrmil subjets thc applicant lo a civil pcnahy of nol mrc lhan fivc hundred dolltrs ($500). _1. as owncr of thc prof,crty, or my employccs with wagcs as thcir solc compensation. will do thc work and thc stnrcturc [s not inten{cd or offered for salc (Sec.70++. Business and Profcssions Code: Thc Contractor's License Law docs not apply to an owner of thc propcrty who builds or improvcs thercon. and who docs such work himsclf or hersclf or through his or hcr own employecs. providcd that such improvcnnnts arc not intended or offcrcd for salc. lf, however. the buitding or improvcrrcnt is sold within onc year of complction, thc Owncr Builder will have thc burden of proving that he or she did not build or improve the propcrty for the purpose of salc). _1. as owncr of thc propcrty. am exclusivcly contracting with liccnscd conlractors to construct thc projcct (Scc. 7W. Busincss ancl Profcsskrn Code: Thc Contractor's Licensc Law docs not apply lo an owner of pro;rcrty who builds or inrprovcs thcrcon, and who contracts for such projccts with a Contractor(s) liccnscd pursuant to the Contractor's Liccnsc hw). lamcxctnptunderScction-.B.&P.C.forthisreason' f t..a,.. WORKERS' COMPENSATION DECLARATION I hcrcby affirm under pcnalty of prjury onc of thc following dcclaralions: _l havc and will maintain a Ccrtificatc of Conscnt to Sclf-lnsurc t'or workcrs' compcnsation. as providcd for by Scction 3700 of the Labor Codc, for thc pcrformancc of thc work for which thc Jrcrmit is issucd. _l havc and witl rnaintain workcrs' compcnsation insurancc. as rcquircd by Scction 3700 of thc l.abor Code. for lhc pcrlbrmance of thc work for which this pcrmit is issucd. My workcrs' compcnsation insurancc carricr and policy nuntbcr arc: _l ccrlily thrt in rhe pcrformncc of thc sork for which this Frmil is issucd. I shall nol cmploy ony lrc]sn in any manrcr $ as ro bâ‚¬om subixt to the workm'@mpcnstion laws of California, and agrc that if I should bccom subjfft to thc workcs'comlrcnsationpDvisionsofScrtion3T0OofthekborCodc,lshall,fonhwith@mplywiththosprcvisions, WARNING: Failurc to sre workcrs' omlrcnsation mvcnge is unlawful, a]d shall subjct an cmplo)cr to qiminal FMltics ud civil fincs up to onc hundrcd thousdd dolhs (S100.0m). in addition to thc cost of comlrcnsation. damScs as providcd for thc Scction 3076 of Ihc lrbor Codc. iilerest sd altomy's fes, Date: Applicant: I ICFNSED CONTRACTOR Dn ct lRATroN I hcrcby aflirm under pcnalty of perjury that I am licenscd undcr provision of Chaptcr 9 (comnrcncing with Section 7000) of Division 3 of thc Busincss and Professions Code, and my liccnse is in full force and effect. Liccnsc Nurnbcr: I 1... ,.. Policy Number: ExPires: W I hcrcby afftrn undcr lEmlty of pcrjury rhor rherc is a construclbn hnding agcncy for thc JErformrcc of thc work for which this Frmit Ls issucd (Src. 3097, Civ. C.). [-cndcr's Addrcss: APPI ICANT NECLARATION I hcrcby allinn undcr penalty of ;rerjury onc of the following declarations: Dcrnolition Pcrmits-Asbestos Notification Fedcral Rcgulations (Titlc 40, Part6) -Rcquircd lrttcr of Notification _l ccrtity that thc fcdcralrcgulations rcgarding asbcstos rcrttovillarc not applicablc lo this projcct. -l certify that I havc rcad this application and statc atxlvc ordinanccs and Statc Laws relating to for is corrcct. I agrcc to comply with all City and County r represenlativcs of this City and County to cntcr upon the l. Carrier: Contrncklr: -r/