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BU!LDING. INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcreby affirm undcr penalty of pcrjury that I am cxempt fmm thc Contractos' Liccnrc law for the following rcuwn (Scc.703l.5 <br />Busincss md Prufcssion Codc): Any City or County which rcquircs r lErmit lo construcl. altcr. impmve. dcfl)lish or rcpair my <br />strucm, prior lo its issusre. drc rcquircs thc lpplkant for such Frmit to filc { sigrcd statcrent that he or slE is liccnsd pusant <br />lo thc prcvisions of the Contractor's Licen$d kw (Chapter 9. Comrcrcing with Sstion 7000 of Division 3 of thc Busircss ud <br />PrcfcssionsCodc)orlhathcorshciscxemptthcrcfromandthcbasisforthcallcgcdcxcmption. Anyviolationofsstion?03l,5byany <br />applicant for a pcrmit subjccts the applicant to I civil pcnalty of not mrc than fivc hundred dollus ($5fi)). <br />-1. <br />as owncr of thc property, or my cmployccs with wagcs as thcir sole compcnsalion. willdo ttrc work and thc stnrcturc is not <br />intcndcd or offercd for salc (Sc.c.7044. Busincss and Profcssions Ccxlc: The Conlractor's Licensc [.:rw docs not apply lo an owncr of <br />lhc propcrty who builds or inrproves thcrcon. and who docs such work himsclf or hcrrclf or through his or hcr own cmployccs. <br />provided that such irnproverncnts arc not intendcd orofTcrcd for salc. lf, howevcr. ttrc building or improvcnrcnt is sold within onc )rcar <br />of cornpletion, thc Owncr Builder will have the burdcn of proving that hc or shc did not build or inprovc thc propcrty for thc purgnsc of <br />sah). <br />-1. <br />as owrrcr of thc properly. anrcxclusivcly c<lntracting with liccnscd contractors lo construct thc projccl (Scc. 7W, Busincss <br />and Profcssion Codc: The Contractor's Liccnsc Law does not apply lo an owner of progrcrty who builds or improves thcrcon. <br />and who conlracts for such projccts with a Contractor(s) liccnscd pursuant to thc Contractor's Liccnsc hw). <br />_l amcxcnlpt undcr Scction_. B. & P.C. for this rcason. <br />Date:_Owner:- <br />WORKEIIS' COTVT PFNSATION <br />DECLARATION <br />I hcrcby al'l'inn undcr pcnalty of pcrjury onc of thc ftrllowing dcclarations: <br />-l <br />have and will maintain a Ccrtificate of Conscnt to Self-lnsurc for workers' comyrcnsation, as providcd for by Scction 3700 of the <br />[:bor Code, fbr thc Jrcrformancc of thc work for which thc pcrmit ls issucd. <br />-l <br />havc and will maintain workcrs' conrpcnsal ion insurancc. as rcquircd by Scct ion 3700 of thc Lahor Codc, for thc pcrfrrrmance of <br />thc work for which this pcrrnit is issucd. My workcrs' compensation insurance carricr and policy numbcr arc: <br />l^S, "a^Ce bwrPav.y <br />i PR,wc lzlLtc{o a oq lmlz.tt'olicy <br />_l ccrtify that in thc pcrforrnancc of thc work fbr which this pcrrnit is issued. I shall n<lt cmploy any pcrson in any manncr <br />so as to becomc subjcct to thc workcrs'compcnsation laws of California. and agrcc thal if I should bccomc subject to lhc <br />workers' compcnsation provisions of Scction 3700 of thc [:bor Code. I shall. forthwith comply with thosc provisions. <br />WARNING: Failurc to sccurc workers' compcnsalion coveragc is unlawful. and shall subject an cmploycr to criminal pcnaltics and <br />civil fincs up to one hundrcd thousand dollars ($100.000), in addition to thc cost of comlrcnsation. damages as provided for thc <br />Scction 3076 of lhc Labor Code. intercst and attorncy's fecs. <br />t lt L\4ta*is ?*,A^n <br />DECI {RATION t <br />I hcreby alllrnr undcr penalty of pcrjury that I anr liccnscd undcr provision of Chaptcr 9 (commencing with Section 7m0) of Division 3 <br />of the Business and Profcssions Code, and my liccnsc is in t'ull forcc and effect. <br />a atslg^t1, <br />€s ectl lar lnc . <br />W <br />I hcrcby aflirm undcr Fnahyof pcrjury thar thm is a construction hnding agcncy for thc lrcrforrorcc of thc work for which this tsmit is <br />issucd (Scc. 3097. Civ. C.). <br />kndcr's Namc: <br />Lcndcr's Addrcss: <br />APPLICANT DECLARATION <br />I hcrcby affrnn undcr penalty of prjury one of the following declarations: <br />Dcrnolition Pcrmits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40, Part6) <br />-Requircd <br />lrttcr of Notilication <br />-l <br />ccrtity thut thc fcdcral rcgulations regarding asbcstos rcnrovalarc not applicablc to this projcct. <br />/r"nrfythat t havc rcad this application and sratc that thc is corrcct. I agrcc to conrply with all City and County <br />ordirranccs and Statc Laws rclating to building authorizc rcprcscnlutives of this City and County to entcr upon thc <br />atxrvc mcntioncd propcrty for inspcction purposes. <br />Applicant or Agent <br />I)crrrrilce nanre k cx-iE a,t1 <br />Dare: - OOlrrl I <br />at <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bf loor/VenVl nsu lation <br />Roof Sheathing <br />Shear Wall <br />Framinq <br />Insulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />N/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif. <br />,A <br />FINAL t0lt3lO,t WtW W <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />-) <br />Expircs: <br />Liccnse .A c CZO Nunrbcr: <br />a