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BU ING.. INSPECTOR RECORD <br />coMr\,[E.:ol'prjury that I atn cxcmpt liom thc rrs' t-icense [.aw for thc following reason (Scc.7031.5 <br />-". -.*.,.. and Profcssion Codc): Any City or County which rcquircs a [Ermit to construct, altcr, improvc, dcmlish or rcpair any <br />struclurc, prbr to its issuance, alm rcquircs the applicant for such Frmil to lile a signed staterenl thal he or $c is liccnscd pumuanl <br />to lhc prcvisions of thc Contractor's Liccnsd ljw (Chaptcr 9, Commcncing wilh Setion 7000 of Division 3 of thc Busincss and - <br />Pmfcssk ns Codc) or that hc or shc is cxcnrpt thsclioin and thc bnsis for lhc allegcd crcmption. Any violalion of Smtion ?03 1.5 by anf <br />applicant for a pcrmit subjccts thc applicant Io a civil penally of not mrc th.n fivc hundrcd dolles (5500). <br />-1. <br />as owncr of thc proJEf,y. or my emplo)rccs with wagcs as lhcil slc comlrcnsalion. willdo thc work ild thc slnnm is mt ? <br />inlcndcd or ofibrcd for selc (Se.?(X4, Busircss and Profcssions Codci Thc Contr{ctor's Liccns law docs not apply to an owncr of , <br />lhc pmFny wlb huilds or irrpmvcs thcB)n. arf,, wlD d(rcs s$h mrk himsclf or hcr*lf or thmugh his or hcr own cmployccs. <br />providcd that such imprcrcmnts rc rel inlendc{ orofFcrc{ for eh. lf, howcrcr, the htilding or inrpmrcilrnt is sH wilhin onc )rce <br />ofcoil{,htion. thc Owncr BuiHcr will haw lhc burdcn ofpmving that hc or shc did not build or impmrc tlrc pDlrcrty for thc puryprc of <br />slc). <br />-1. <br />as owncr of thc propcrty. am cxclusivcly conlracting with liccnsed contraclors to construct thc projcct (Scc. 7W. Busincss <br />and Profbsskrn Codc: Thc Contractor's Licensc Law does not apply lo an owner of property who builds or improves thcreon. <br />and wh<l conlracts f'or such projccts with a Contractor(s) liccnsed pursuant to lhc Contraclor's Liccnsc Law). <br />_l arn cxcrnpt utrdcr B. & P.C. for this rcason. <br />WORKERS' COMPENSATION <br />DT'CLARATION <br />I hcrcby affirrn undcr pcnalty of pcrjury one of thc following dcclarations: <br />-l <br />have and will maintain a Ccrtificate of Conscnt to Self-lnsurc for workcrs' compensation, as provided for by Scction 3700 of thc <br />I-;rbor Code. for thc pcrfonnancc of the work for which thc pcrnrit is issued. <br />-l <br />have and will maintain workcrs'compcnsation insurance. as rcquircd by Scction 3700 of thc l-abor Code, for thc pcrfornrance of <br />thc work for which this prrnit is issued. My workers' compcnsation insurance carrier and plicy numbcr are: <br />Date: Owner:_ <br />Policv Numbcr: Exoires: <br />-l <br />ccrtify that in thc performancc of thc work for which this pcrmit is issucd. I shull not crnploy any pcrson in any manner <br />so as to bcconrc subjcct to the workcrs' cornpensation laws of California. and agrec lhat if I should bccomc subject to thc <br />workcrs' compcnsation provisions of Scction 3700 of thc t-abor Code, I shall. forthwith comply with thosc provisions. <br />WARNING: Failurc to sccure workers' compcnsation coveragc is unlawful. and shall subjcct an cmployer to criminal penaltics and <br />civil fines up to onc hundrcd thousand dollars ($100.000). in addition to lhc cost of conlpcnsation. damagcs as provided for the <br />Section 3076 of thc Labor Codc. inlercst and altorney's fccs. <br />Date: <br />a <br />DECII\RATIQN <br />I hcrcby all-rrrn undcr penalty of pcrjury that I anr licenscd undcr provision of Chrptcr 9 (conrmencing with Scction 7000) of Division 3 <br />of thc Busincss and Profcssions Code. and my liccnsc is in full forcc and cffcct. <br />Licensc Class:_ <br />Date: <br />Nurnhcr: <br />CoNSTRUCTION LENDIN(: AGENCY <br />I hcrcby allirtn undcr lrcnulty of pcrjury thal lhcrc is a construction lcnding agcncy for thc Frformncc of thc work for which this Ismil is <br />issucd (Scc. 3097. Civ. C.). <br />Lcndcr's Nanrc: <br />Lcndcr's Addrcss: <br />APPLICANT DBCI ARTilTION <br />I hcrcby affrnn under pnalty of pcrjury onc of thc lbllowing dcclarations: <br />Dcmolition Permits-Asbcstos Notification Fedcral Rcgulations (Title 40. Part6) <br />-Rcquircd <br />lrttcr of Notification <br />-l <br />ccnifi that thc fcderol rcgulutions rcgading &sbcstos rcmval arc not applicablc to this pmjct. <br />-l <br />ccrtify that I havc rcad lhis applictrtion urd st{tc thsl thc obovc inforrolion is corcct. I agre lo comply with all Cilyand County <br />ordinanccs snd SIate kws rclating to building construction. ard hcrcby authorizc rcprcsntatircs ofthis City ad County lo cnter ulDn thc <br />abovc rcntioncd prcpcny for inslEction purlDrcs. <br />Applicunt or Agent <br />I'ernrilee nanre <br />t <br />t <br />SITE.WORK DATE ID/SIG.\ <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bf loor/Ve nt/l ns u I atio n <br />Roof Sheathinq <br />Shear Wall <br />Framinq 7-l{-Z t rE<rrrl 4t <br />lnsu lation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Jt/asonrv <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />FINAL <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />Applicant: <br />Signature: Date:_