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BUILDING. INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />t hcrcby alnrm undcr pcnalty of Frjury that I am excmpt ftom thc Crntraclos' Liccnse ljw for thc following rcasn (Scc.7031.5 <br />Busincss aml Profcssion Codc): Any City or County which u1uircs a Jrcmit to construct. altq, imprcvc. dcmlish or rcpair any <br />structurc, prfur to its issuancc, also rcquires the applicant for such permit to filc a signcd slatcrent lhat hc or shc is liccn$d pusmt <br />lo lhc prcvisions of thc Contractor's Liccnsed tjw (Chapler 9, Commncing wilh Section 7000 of Division 3 of thc Busincss and <br />PmlbssionsCodc)orthaihcorshciscxcmptttscfrcmondthcbasisforthcallcgcdcxcmption. AnyviolationofSctknT03l.5byany <br />applicant for r permit subjets thc epplicant lo a civil pcnalty of not mrc than fivc hundrcd dollus ($50O). <br />_1. as owncr of thc propcrty, or nly cmployccs with wagcs as tlrcir solc cornpcnsation, will do thc work and thc structurc is not <br />intcrxlcd or olTered filr salc (Sec.7044, Business and Profcssions Codc: Thc Contractor's Liccnse [.aw docs not apply lo an owncr of <br />thc propcrty who builds or irnprovcs thcrcon, and who dcrcs such work hirnsclf or hcrsclf or through his or hcr own cmployccs. <br />providcd that such irnprovcrrrcnts rrc not intcndcd or offcrcd for salc. If, howcvcr. thc building or itnprovcnrcnt is sold within onc ycar <br />of conrphtion. thc Owncr Buildcr will havc thc burdcn of proving that hc or she did not build or improvc thc pnoperty for thc purJx.rsc of <br />salc). <br />_1. as owncr of thc propcrty. am exclusivcly contracting with liccnscd contractors lo construct tlrc projcct (Scc. 7044. Busincss <br />and Profbsskrrr Codc: Thc Contractor's Licctrsc Law docs not apply to an owncr of propcrty who builds or improvcs lhcrcon. <br />and who contracts for such projccts with a Contractor(s) licenscd pursuant to thc Contractor's Licensc t-aw). <br />_l arn excnrpt undcr Scct B. & P.C. tbr this rcason. <br />Date:_0wner: <br />WORKERS' COMPENSATION <br />DF'CLARATION <br />I hcrcby afllrm undcr pcnalty of perjury onc of thc following declarations: <br />_l have and will rraintain a Ccrtificatc of Conscnt to Self-lnsurc for workcrs'comlrcnsation, as providcd for by Section 3700 of thc <br />for thc pcrformancc of37fi) of thc Labor Codc. <br />and policy numbcr arc: <br />Policy O7/L/ <br />_l certity that in thc perlbrmancc of thc work for which this Jrcrmit is issued. I shall not cmploy any person in any ntanncr <br />so as to hcconrc subjcct to the workcrs' cornpcnsation laws of Calilbrnia, and agrcc that if I should bccomc subject to thc <br />workcrs' com;rcnsation provisions of Scction 3700 of thc l--abor Codc. I shall. forthwith comply with thosc provisions. <br />WARNING: Failurc to sccurc workcrs'an to criminal penaltics and <br />civil lincs to one hundrcd thousand darnagcs as providcd for thc <br />Code. intcrcst <br />I ICENSED CONTRACTOR <br />DECLARATION <br />liccns;cd undcr provision of Chaplcr 9 (commencing with Scction 7000) of Division 3I hercby alllrnr undcr pcnalty of pcrjury that I ant <br />of thc Busincss and Prol'cssions Code. and my liccnse is in full force an<l cfl'cct. <br />Liccnsc <br />W <br />I hcrcby aflirm undcr Jrcnalty of pcrjury rhil thcrc Ls . construction hnding agcncy for thc Isformncc of thc work for which this Jrcrmit is <br />issucd (Se. 3097, Civ. C.). <br />Lcrttlcr's Nalnc: <br />[.cndcr's Address: <br />APPLIC ANT NF'CLA RATION <br />I hcrcby affrrn undcr penalty of pcrjury onc of the following declaratiolts: <br />Dcnrolition Pcrmits-Asbcstos Notification Fcderal Rcgulations (Title 40. Pan6) <br />-Rcquircd <br />l.ettcr of Notification <br />_l ccrtily that thc l'cdcral rcgulations rcgarding asbcstos rcrnoval arc not applicablc to lhis projcct. <br />_l ccrtify that I havc rcad this application and statc that with all City and County <br />and Crynty to crlcr u;xrn lhc <br />s/p/ L7 <br />ordinances and State [-aws rclating to building <br />abovc mcntioncd propcrty for <br />Applicant or Agent <br />Pernrilee nanre (print): _ <br />Jlolo. <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf Ioor/VenVl nsu lation <br />Roof Sheathinq 7/z/>^.LzilZo <br />Shear Wall (t /- <br />Framinq <br />lnsu lation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />[\Iasonrv <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif . <br />t nl <br />FINAL 9/rr/z Jal*-t <br />Certificate of Occupancv I tv <br />Notes, Remarks, Etc. <br />_Liccnsc