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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELC]ARATION <br />I hcrchy allirm undcr IEnalIy of Frjury thrt I am cxcmpt h(rm lhc Grntractos' Liccn* kw tirr thc followitrg rca$n (Scc.7031.5 <br />Busincss anl Profcssion Culc): Any City or County which rcquircs , Imit to construcl. ahcr. improve. &mlish or rcJEir uy . <br />structurc, pri(lr t() its issuance, also rcquircs thc applicant for such lrmit k file a sigrcd ststcmnt that he or strc is licinsd pusuant <br />Io thc provisions of thc Conlractor's Liccn$d liw (Chaptcr 9, Commcreing wilh Sccti.rn 70fi) of Division J of thc Busincss and <br />Profbssions Codc) or that hc or shc is cxcmpt thcrcfrom and thc hasis for thc allcged cxcmption. Any violation of Scction 703 1.5 byitry <br />applicant for a Frmit subjccts thc applicant k, a civil pcmlty of not morc thsn five hundrcd dolles ($500). <br />_1. as owncr ol'tlrc propcrty, or my cmployccs with wagcs as thcir solc compensation. will do lhc work and thc slruclurc rs not <br />intcntlcd or ()ll'crcd lor sale (Sec.7044, Busincss and hotbssiuns Crxlc: Thc Contractor's Liccnse Law drrcs not apply to an owncr of <br />thc pnrpcrty who buikls or improvcs thcrcon, antl who docs such work himsclf or hcrsclf or lhrcugh his or hcr own cmployccs, <br />prlvitlcd that such impnrvcrncnts arc mrt intemlcd or oftbrcd lbr salc. It. howcvcr, thc building or impnlvcnrcnt is sokl within onc yc:u <br />of complction, thc Owncr Builder will have thc burdcn ol proving that hc or shc did not build or improvc thc proJrcrly lirr thc puryrs'e o[ <br />salc). <br />-1, <br />as owncr ol'thc prcJrcrty, am cxclusivcly contractfurg with liccnscd contractors to construct thc project (Sec. 7M4, Busincss <br />and Pnrlbssion Codc: Thc Contraclor's l-iccrrsc Law docs not apply lo an owncr of prcpcrty who builds or improvcs thcrcon. <br />and who contracts for such projccts with a Contractor(s) licclrscrl pursuant to thc Contractor's Liccnsc Law). <br />-IamcxcmptunderScction-'B'&P.C.tilrthisrcason'I\., r ^. <br />WORKERS' CONI PENSATION <br />DECLAITATION <br />I hcrchy all'irm untlcr Jrcnalty of Jrcrjury onc ol'thc lilllowing dcclarations: <br />_l havc and will maintain a Ccrtilicatc ol'Conscnt kr Sclt'-lnsurc tilr workcrs' compcnsation. as pnlvitlcrl for by Scction 1700 of thc <br />[:hrr CtxJc, tirr thc pcrformancc of thc work lirr which thc pcrmit Ls issucd. <br />_l havc and will maintain workcrs'comJrcrrsation insurancc, as rcquircd byScctionlT0Oof thc LahorCorlc, torthc Jrcrlirrmanccof <br />thc work tilr which this pcrmit is issucrl. My workers' comlrcnsatiorr insurancc carricr and pllicy numhcr are: <br />.tcuni"r. All;a*il lqlttttg,< 5cw;ccJ , lt*' <br />poricy Nun.,b"r. GA looo {o et ta I Expires:lO - I '?ott <br />-I <br />ccnity that trr thc Jrcrli)rmftc (r[Ihc work tbr which Ihis JErmil is issucd. I shall not cmpk y any Frson in eny manncr :'s as to heqrm subjcct to thc wortss' comlf,nsation laws of California, and 09rc lhal if I should bouom subjet k thc <br />workcrs' comlEnsation provisions of Setion 3700 of tlrc tahrr Cqlc, I shall, tbrthsith comply sith tho* prcvisions. <br />WARNING: Failurc to scuc rurkcrs'comlrcnsation covcmgc is unlawful, aftl shall suhjcct {n mployer kr qimiml Fmltics and <br />civil lines up to onc hundrcd thousanrl dollars ($100,(Xrc), in atldition to thc cost of damagcs as provitlcd tirr thc <br />Scction J076 ot'thc Latxrr Crxlc, intcrcst and attrlrncy's f'ces. <br />Da,". L'6 ' UZt <br />I hercby allrrm under pcnalty of prjury that I am liccnscd 9 (comnrcncing with Scction 7firu) of Division 3 <br />of thc lJusincss and Prol'essions Codc, and my liccnse is in ltrll lirrcc antl cll'cct. <br />Liccnsc ctors FA Liccnsc Numbcr:rt ro <br />Dare: 2,-U' ZOl, <br />I hcrcby allirm undcr Jrcnalty of Jrcrjury that therc <br />issucd (Scc. .1097. Civ. C.). <br />a constructi()n agcncy firr thc Jrcrlornrancc of thc work lilr which this pcrmit is <br />I-cndcr's Addrcss' <br />APPLICANT DECLARATION <br />I lrcrcby atl'rrn unr.lcr pcnalty of prjury onc of thc folkrwing rlcclarations: <br />Demolition Pcrmits-Asbcstos Notil'ication Fcrlcral Rcgulations (Titlc 40, Pafl6) <br />_Rcquircd lrttcr of Notification <br />-l <br />ccnily tlut lhc fcdcralrcCulali(rns rcgatrdiDg asbesk)s rcnxlvalec ml applicablc b lhis ps)jel. <br />_l certify thal I havc rcad this application anl statc that thc atDvc informlion is corccl. I a8rc lo comlly sith all Cily and County <br />ordinanccs and Statc Laws rclating to building construction, drt hcrcby aulhorizc rcJrcrcntalivcs ofthis City and Coutrly to cnlcr uIx)n the <br />atxlvc mcntionctl proprty lilr inspcction <br />Applicant or Agtnt <br />Pennitee nanlc (prinl):T**- D,+"f. oe c , <br />o^r", 2't- (DZl <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/Ve nV! ns u latio n <br />Roof Sheathing <br />Shear Wall I I I l- <br />Framing 1t,Dl+#6 t <br />Insu !ation/Energy <br />Drywall L '?/rfLt D\qoffif 4 <br />Ext./lnt. Lath \[ I <br />Brown Coat <br />J\Iasonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />A-t <br />F!NAL lo t617 DWF6 7 <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />Elav n9,-n7 9n 1 6 <br />lrndcr's Namc: <br />(o -A <br />t,