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BUILDING. INSPECTOR RECORD <br />SITE,WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcrchy anirn undcr Fnalty of lrcrjury that I am cxcmpt from lhc Conlractos' Liccnsc [:w lor lhc tirlkreitrS rca$n (x*.70]1.5 <br />Busincss anl Profcssion C*Ic): Any City or County which rcquircs a Frmit lo construcI. alttr. impr(rvc. demolish or rcJtsir any <br />struclure, Fi()r lo ils issuancc, also rcquircs thc rpplicaDt for such Fmit k, lilc a signcd strtcmnt that hc or slrc is liccnscd pmuet <br />to lhc pruvisi(nts of thc Contractor's Liccnrcd trw (Chaptcr 9, Commcruing with Scction 70fi) of Division .l of thc Busincss and <br />ProlbssionsCode)orthathcorshciscxcmptthcrcfromandthcbasisforthcallcgcdcxcmption. AnyvkrlationofscctionT03l.5byany <br />applicant ti)r a lrcrnrit subjccts thc applicant to a civil pcnalty of not morc thdn livc hundrcd dolles ($5OO). <br />_1, as owncr ol'thc propcrty, or my employccs with wagcs as thcir solc comfrcnsation, will do thc work and thc structurc is not <br />interxJcd oroll'ercd lirr salc (Scc.7044, Busincss and Prof'cssions CuJc: Thc Contractor's Liccnsc [:w dtrcs not apply to an owncr of <br />the pnlpcay wlxl huikls ()r improvcs thcrcrrn, anl who dtrcs such work himsclf or hcrsclf or through his or hcr own cmpklyccs, <br />providcd that such improvcrncnts arc not inlcnlcd or otlbrcd fbr sah. It, txlwcvcr, thc buikling or improvcnrcnl is sokl within onc ycar <br />of complctk)n, thc Owncr Buildcr will havc thc burdcn o[proving that hc rlr shc rlid not buikl or improvc thc pnr;r'rty lirr the purJxrsc of <br />sale). <br />_-1, as owncr of thc pro[rcrty, am cxclusivcly contracting with liccnserl contractors to construct the projcct (Sec. 7M4, Busincss <br />and Pnrli:sskrn Codc: Thc Contractor's Liccnsc Law drrcs not apply to an owncr of proJrcrty who builds or improvcs lhcreon, <br />and wlxr contracts lilr such projects witlr a Contractor(s) liccnscd pursuant to thc Contractor's Liccnsc Law). <br />_l am cxcmpt undcr B. & P.C. for this rcason. <br />f\.rla. <br />WORKERS' COTIIPENSATION <br />DECLARATION <br />I hcrcby aftirm undcr pcnalty of pcrjury onc of thc tirlklwing declarations: <br />-l <br />have and will maintain a Ccrtiticatc of Conscrrt to Sclt'-lnsurc tor workcrs' comJrcnsation, as pnlvidcd tbr by Scction 3700 of the <br />Labor C<xlc, lbr thc pcrlirrmancc of the work ftrr which thc pcrmit is issuctl. <br />_l have and will maintain workers' comJrcnsation insurarrce, as rcquircd by Scction 37fi) of the Labor Codc. for thc pcrfbrmance of <br />thc work lbr which this pcrmit is issued. My wrlrkcrs' comlrcnsation insurancc carricr arxl Jxllicy numbcr arc: <br />canicr: \ 9lq\C Corn em6c.{ic/n aF.r9 FrrnJ <br />Pohcy - tqaQgoll q tf- t-)-0 1l <br />_l ccrtily that irr thc Jrcrftlrnrancc of the work tilr which this Jrcrmit is issued, I shall not cmpkry any pcrson in any manncr <br />so as l() bcconrc suhjcct to thc workcrs' comJrcrrsation laws of Califbrnia, arrd agrcc that if I should bccomc subjcct to lhc <br />workcrs' compcnsation provisions of Scction .3700 ol'thc Lahlr Codc, I shall, lorthwith comply with thosc pnrvisions. <br />IVARNING: Failurc to sccurc workcrs' compcnsation coveragc is unlawlul, and shall sub.icct an cmployer to criminal Jrcnaltics and <br />civil lincs up lo onc hundrcd thousand rkrllars ($lU).m0), in addition to thc cosl ol'compensation, danragcs as providcd fbr thc , <br />Section 3076 of thc l-ahrr Ctxlc, intercst and ( <br />I\.-. ^ .2-*l[ -:-l <br />I hercby atlrrnr unrlcr pcnalty ol'prjury that I am liccnscrl 9 (commcncing with Scctiort 7firu) of Division 3 <br />of thc Busincss artd Prot'cssiotts Corlc, ard my liccnsc is in tull filrcc urd cll'cct. <br />F <br />Liccnsc <br />q <br />I <br />W <br />I hcrcby aflirm undcr pnalty of pcrjury that thcrc is a qrnslructi)n bndfuU a8crey li)r thc Frfomncc of lhc work for which this pcrmit is <br />issucd (Scc. J(x)7. Civ. C.). <br />[anlcr's Namc: <br />[rndcr's Addrcss: <br />APPLTCANT DECLARATION <br />I hcreby atlim undcr pcnalty of ;rcrjury onc of thc lirlkrwing declarations: <br />Derrxrlition Pcrmrts-Asbcstos Notification Fcdcral Rcgulations (Titlc 40, Part6) <br />_Rcquircd lrttcr of Nrxilication <br />-l <br />ccrlily that thc lbdcral rcgulations rcgzutlinS oshcstos .cmval e not applicnhlc kr lhis projcct. <br />f, Ln, ,nr, I havc rcarl this application ild statc that thc ahrve infirrmatiur is corcct. I agrc to comply wilh all City and County <br />ordinanccs aDd Stntc Laws rclaling to building construction, atrl hcrcby authorizc rcltrcsntalivcs ofthis City ond County b cnts ulDn lhc <br />atxrvc mcntionccl pnrJrcrty lirr <br />Applicant or Agent <br />Pernritee nanle <br />o"t.' 2- E -) l <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf !oor/VenUl ns u latio n I <br />Roof Sheathing -7 Dqct(e;1 <br />Shear Wall t I) <br />Framing r <br />Insu lation/Energy vl <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />[\Iasonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif . <br />Ir , <br />FINAL q t0 A WWT 7 <br />Certificate of Occupancy -l <br />Notes, Remarks, Etc. <br />nq-n7 -2n 1 tr <br />/ <br />'51 tlA