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BUILDING. INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG.COMMENTS OWNtsR BUILDER DELCARATION <br />I hcrcby allirm undcr Fnalty of lErjury that I m cxcmpl liom tlrc CotrlracloF' Liccns kw tbr thc following rca$rn (Scc.?011.5 <br />Rusincss anl Profcssion Culc); Any City or County which rcquircs I lErmit k) construct. alts. improve, demolish or rcpair any <br />struclurc, prior to ils issuancc, also requircs thc .pplic.nt lbr such [rrmit to lilc a sigrcd statcmnt that he or slE is liccnsd pffiuant <br />to thc lmrvisklns of tlrc Conlnctor's Liccn$d llw (Chsltcr 9. Commcncing with Scction 7fi)O of Division 3 of lhe Busincss and <br />Pmlcssions Codc) or thal hc or slrc is cxempt thcrcfrom and thc basis for thc allcgcd cxcrDtion. Any violation of Scttun 701 1.5 by any <br />applicanl tirr a pcrmil subjets thc applicant to a civil pcnalty of nol morc than fivc hundrcd dollds (S500). <br />_1, as owncr of thc propcrty, or my employecs wilh wages as thcir vrlc comJrcnsation. will do thc work aflJ thc stru.*turc is not <br />rntcrxlcd or olfered firr salc (Scr.7M4, Business and hol'essions Crxlc: Thc Contractor's License law does not apply to an owner of <br />thc pnrJrcrty who buikls or improves thcrcnn, arxl wlxr docs such work himsclf or hcrsclf or thrlugh his or hcr own employccs. <br />pnrvidcd that such improvcnrcnts arc not intcnded or oll'crcd lirr salc. If, trrwcvcr, thc buikling or improverrpnt is sokl within onc yciu <br />ol'complction, thc Owner Bui.kler will havc thc burdcn ol'pnlving that hc or shc did not buill or impnrvc the pmpcrty for thc purposc ol' <br />sah). <br />__1. as owner of thc property, am exclusivcly contracting with liccnscd contractors to construct thc projcct (Sec. 7(X4, Business <br />and Prulbssion Crx.lc: Thc Contractor's Liccnsc Law dtrcs not apply to an owncr of proSrcrty who builds or improvcs thcrcon, <br />and who contracts for such projccts with a Contractor(s) liccnscrl pursuant to thc Contractor's Liccnsc Law). <br />-IamcxcmptundcrScctitln-'B.&P'C.tilrthisrcastln. <br />f l.i. ^. <br />WORKERS' CONIPENSATTON <br />DECLIIBAIIAN <br />I hcrcby afiirm undcr Fnalty of pcrjury onc of thc fbllowin8 dcclsrotions: <br />-lhavcanlwillmintainaCcrtifreatcofcon$nttoSclf-lnsurcforwrrkcrs'crrm;rcnsation,as <br />FovidcdforbySetion-17U)oflhc <br />tatxr Oxlc, for thc ;rcrfomfrt of thc work tbr which thc JEmit ir issucd. <br />OU havc ancl will maitrtain workcrc' comJEnsation insurarec, as ,cquircd by SNlion -1700 of thc kbor Codc, for thc [trtormnc! of <br />thc work for which this Jrcmit i! is$ql. My works' com;rcnstion insurancc cuicr anl JDlicy number de: <br />AIE-Arn e,r.t (^^, T/vs. Cnt^n oPn^/\JL-3i-xPolicyLI <br />_l ccrtily that in thc Jrcrlilrmancc of thc wrlrk tirr which lhis prmit is issuctl, I shall rxrt empkry any pcrson in any manncr <br />so as lo bcconrc subjcct to the workers' comJrcnsation laws of Calitilrnia, and agrcc thal if I should bccomc subject to thc <br />workcrs' compcnsation pnlvisions of Scction 3700 of thc Lahlr CrxJc. I shall. lilrthwith comply with thosc provisions. <br />WARNING: Failurc to sccurc workcrs'comprcnsation covcragc is unlawl'ul, and shall subjcct an cmpklycr to siminal pcnaltics and <br />civil lincs up to onc hundrcd thousand dollars ($100,Uru), in addition lo thc cost of comlrcnsation, damagcs as provided lilr thc <br />Scction 3076 of thc Labor CtxJe, intcrcst and attorncy's l'ccs. <br />o"t.,b8-L\ <br />I hcrcby allirm undcr pcnalty of pcrjury that I arn liccnscd undcr pnrvision of Chaptcr 9 (commcncing with Scction 7000) of Division 3 <br />of thc Busincss and Prot'cssions Codc, and my liccnse is irr lirll firrcc and cft'cct. <br />l-iccnsc Nunrbcr: <br />q <br />B- <br />W <br />I hcrchy all'irm undcr pcmlty of pcrjury that th6c is a constructk)n bnilinS rgcncy for thc lsfbmnce of thc vork for vhich lhis JEmit is <br />issucd (Ss. -1097, Civ. C.). <br />[lndcr's Nam: <br />lrndcr's Address: <br />APPLICANT DECLARATION <br />I trcrcby aflrm undcr grcnalty of perjury one of thc folklwing dcclarations: <br />Dcmolition Pcrmits-Asbcstos Notification Federal Rcgulations (Titlc 40, Part6) <br />_Rcquircd lrttcr ol' Notilication <br />_l ccrtity that the t'cderal rcgulations rcgarding asbcstos rcmoval arc not applicahlc to this project. <br />!f ."rtify thar I havc rcarl this application anrl statc that thc ahrvc inlirrmatklr is corrcct. I agrce to comply with all City and Cuunty <br />ordinanccs and Statc Laws rclating to building c<lnstruction, and hcrchy rcprcscntativcs of this City and County to cntcr uJxrn the <br />atxrvc nrcnlioncd proJrcrty lirr <br />Applicant or Agent <br />Penuilee nanre oLo <br />$-zl'\^e --l 8-2i <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bf loor/Ve nVl ns u latio n <br />Roof Sheathing <br />Shear Wall <br />Framing <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />lVasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />///-e <br />F!NAL ZlLL lzt Jlr gL <br />Certificate of Occupancy tl <br />Notes, Remarks, Etc. <br />Elorr nR-n7-2n 1 q