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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUII,DER DELCARATION <br />I hcrhy allirnr undcr lrcnalty ol Frjury that I am c\cmpt lh)m thc Contrnckns Liccnsc hw lirr thc following rcasn (Scc.?O.ll.5 <br />Busincss ail P(rtcssion Codc): Any City or Courty which rcquircs a Jrrnit k, (r)nstruct. allcr, imp(rvc. dcmrlish or rcprir any <br />slructurc. pri)r k) its issu{trcc. also rcquircs thc applicant li}r such lEnnil k) lilc n signcd statem'trt lhal lrc or shc is liccnscd pursuanl <br />to lhc [m)visi()ns of lhc Contrackrr's Liccnscd llw (Chnplcr 9. Conrmefting with Scction ?Un of Division 3 (]f lhc Busincss and <br />Prolbssions Codc) or that lrc or shc is cxcmpt thcrcliom and thc hasis ti)r thc rllcgcd cxcnlption. Any violation of Sccttrn 70-l I .5 by {ny <br />rpplicanlforalrcrmitsuhjcclslhc applicanltoacivilpcnaltyo[n(]tmorcthunlivchundrcddollrs(3500). <br />_1. as owncr ol'lhc pn)lrcrty. ()r tny cmployccs wilh wagcs as thcir solc conrpcnsrlion. will do thc wrlrk ard thc structure is lx)t <br />intcrrdcd or oll'crcd lirr salc ( Scc.7044. Business anrl Proll'ssions Crxlc-: 'l'hc Cirntractor's I -iccnse l.aw docs not apply lo an ttwncr ot' <br />thc pnrpcrly wlxr buikls rlr impnlvcs thcrcon. aml who tkrcs such wrxt hinrscll'or hc'rscll'or lhrough his or hcr own entpl()yccs. <br />provitlcd that such inrprlvcrncnls arc n<lt inlcndcd or ollbrcrl lilr salc. I[. lrtlwcvc-r, thc huikling or improvenrcnl is sokl within ()nc yr'iu' <br />of con4rlction. tlrc Owncr Buildcr will havc lhc burdcn ol'pnrvirrg lhal lrc or slrc did not buihl or inrprrtvc thc prrt;u1y lilr lhc purposcol' <br />sah). <br />and lhrlbssirnCrdc: 'l'hcConlraclor's[-iccnscLawrlocsrrolapplvlo:rnowrr('rol'pro1^*rtywhohuilds<lrimproveslhc'rr'ttn. <br />anrl wlrrl conlracts lirr such projccts with a Contrirctor(s) liccnscd pursuanl lo lltc Crxttritclrlr's l.iccltsc l.aw). <br />-IamexenlplundcrScclion-.B.&P.C.tilrlhisrcasrtn. <br />lVORKERS' COt\I PENSA'TION <br />DECLARATION <br />I hcrc:hy all'irnr undcr pcnalty ol'pc{ury onc ol'thc lirlkrwirrg rlccl:rrations: <br />_lhavcarxlwill nrainlainaCcrlilicatcol'ConscrrtloSclt-lrrsurclirrworkcrs'contpcnsali()n.as providcdlirrbyScctiolt-]7fi)ofthc <br />Lalxrr Codc, tirrthc lrcrlirrmancc o[the work lilr which thc pc'rrnit is issucd. <br />_l havc and will maintain workcrs'conl[rcnsation irrsurancc. as rcquirc'd hySr-ction -17(X)ol'thc l.ahor(iilc. fitrthc lrcrlilrntanccol' <br />thc work tirr which lhis permit is issucd. My wrlrkcrs' c()mlrclrsaliorr insuritncc carricr antl ;xrlicy rtunrhcr arc: <br />Policy Numbcr: Expirc's: Ab- <br />_l ccrtitythat in thc;rcrlirrmancc o[thc work lirr which lhis pcrnrit is issuctl. I shall not cmpkry ilny pcrson in any nrdnncr <br />so as lo hcconrc subjccl lo thc workcrs'conr;rcnsatiotr laws ol Califtlrnia. and agtcc that il'l shoultl hcome sulljcct ft) llrc <br />workcrs' conrlrcnsation pr)visiorrs of Sccl ion .l7U) ot'thc l-alxrr Crxlc. I shall. lirrthwith contply wrlh thosc provisi.9,s. <br />WARNING: Failurc to sccurc workers' comJrcnsati()n covcrilgc is unlawhrl. anrl shall suhject an cmpktycr t() critninal pcnaltics and <br />Scclion -1076 ot'lhc [.ahrr Crxlc. inlcresl iurd attorncy's l-ccs. <br />Dale: <br />LICENSED CONTRACTOR <br />DET]LARATION <br />ol' llrc Busincss and Prol'cssiorrs Clodc, and my liccttsc is irt lirll lirrct- :uttl cl'tcct. <br />Licensc Class: l-iccnsc Number: <br />l)ale : <br />W <br />I hcrchy altirm undcr Jrnillly ol pcrjury that lhcrc is r conslrction lcndi[g agcncy li)r thc pcrli)nnancc of lhc work lirr which lhis lrnnit is <br />issucd (Scc. l(rr7. Civ. C.). <br />I.cntlcr's Nanrc: <br />lrndcr's Addrcss: <br />APPLICANT DF]CLARATION <br />I l**rc-by allinn unrlcr J^-nalty ol'p-rjury orrc ol'thc lirlkrwing tlcclarations: <br />Dclnolilion Pcrnrits-Asbcstos Nolil'ication l;crlcral Rcgulations lTitlc 40. Pun6) <br />_Rcquirctl Irltcr ol' Nriliticaliorr <br />_l ccrlily lhal thc ll'dt:ralrcguhtions rcgiuding ashcstos rcnxrvalarc n()l applicahlc lo lhis projccl. <br />_l ccrtily lhal I havc rcatl this applicatiorr with all City and County <br />arrd Counly to eltlcr uprn lltcorrlilr:urccs antl .Stalc I-aws <br />atxrvc' nrclrt iorrctl proJxrly lirr <br />Applicarrl or Agent <br />I'enrrilt t nAnrc <br />sl:rlc llurl <br />J -/ <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bf loor/Vent/l ns u lat io n <br />Roof Sheathing <br />Shear Wall <br />Framing <br />Insulatio nlEnerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />l\/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />,r^, <br />FINAL lo-5-?l Dn r/l [ )t <br />Certificate of Occupancy <br />\Notes, Remarks, Etc <br />Annlicrrnl: <br />arrtl lrcrc'tly ittt I lx rrizr'