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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcrchy dflirm un'lcr lEmlly of Frjury lhat I am cxcmpl lt)m the ConlractoN' Liccnsc tlw lbr the tirllowing rcavrn (Scc.70Jl.5 <br />Busincss anl Prolbssion CuIc): Any City or Coutrty vhich rcquircs a Jrrmit to corotruct. altei improvc. dcmolish or rcpair atry <br />struclurc, ltri(]r t(] its issuancc, also rcquircs thc opplicant for such JErmit to lilc a signed statcmnt that hc or shc is liccnsd pursuant <br />k, thc pmvisims of thc Gnilrackrr's Liccnsd llw (Ch0plcr 9, Commcncing with Setion 7(XX) of Division -l of lhc Busincss and <br />Prrlcs$()n$ Codc) or that hc or shc is cxempt thcrcfrom and thc basis tbr thc allcgcd cxcmplion. Any violalion of Setkrn 70J 1.5 by any <br />applicant li)r d trcmit subjccts thc applicant k, a civil pcmlty ofnot morc than fivc hundrcd dolles ($500). <br />_i, as owncr ol'lhc propcrly, or my cmployccs wilh wagcs as thcir sole compcnsation. will do the work and thc strur,*turc is nol <br />urtc'ndcd or ol'lcrcd lirr salc (Soc.7(X4, Busincss and Prot'cssions C<xic: The Grntractor's Liccnsc [^aw does not apply to an owncr of <br />lhc pnlJrcrty who huilds or improvcs thcrc.t)n, arxl wlxr drrcs such work himsclf or hcrsclf or through his or hcr own cmployccs, <br />provirlcd that such improvcnnnts are not intcrxlctl or ol'tercd tirr sah. If, txrwcver, thc huikling or improvcrncnt is sokl within onc ycar <br />of complction, thc Owner Buildcr will havc thc hurdcn ol'pnrving that hc or shc did not buikl or improve the propcrty lirr thc purytsc of <br />salc). <br />_1. asowncrol'thc proJrcrty, amcxclusivclycontracting with liccnscd contractorstoconstruct the project (Sec.7U4, Busincss <br />arxl Prulbsskln Codc: Thc Contractor's Liccnsc Law docs not apply to an owner of propcrty who builds or improves thcrcon, <br />and who contracts lilr such pnrjccts with a Contractor(s) licenscd pursuant to thc Contractor's Liccnsc taw). <br />_l anr cxcmpt undcr B. & P.C. tirr this rcason. <br />flo I a.A.--o-' <br />TASSEBSIOII8IN$AIION <br />DECI.AEAIION <br />I hcrcby afl-rm undcr Fnalty of tsjuryorc of thc following dsltrations: <br />-lhavcafilwil! <br />mintainrCcrtificatcofconsnttoSclf-lnsurcforworkss (rmFnsation,as FovidcdforbySetion3T00oflhc <br />t xrr Codc, for lhc lEfomrec of thc work for which thc lErmit is issuc{. <br />l]f,l have anrl will mintain workcrs' comlEnsati(rn insunrec, as rcquircd by Setion 3700 of the kbor Ctxle, for thc pcrforrorec of <br />thc work for which this lEmit is issuca!. My workcs' comlrcnsation insurance cMier ani;relicy number rc: <br />frU <br />Policy LLC b D-3'7l <br />_l ccrlify that in thc [rcrlbrmancc of lhc work lbr which this J,crmit is issucd, I shall not cmploy any lrer$)n in any manncr <br />$ astobocomsubFcttothcworkers'comlEnsationlawsofcalilbmia,andrgrcthstiflshouldbccomsubjctttothc <br />workss'q)mpcnsationpmvisionsofscction.l?00ofthclatrrCrxlc,lslEll,tirnhwithcomplywithtksprovisions. <br />WARNING: Frailurc to scurc workcrs'compcnsation covcruSc is unlawful, and shall subjct m cmploycr to qiminal JEmllics and . <br />civil linc$ up k) onc huulrcd thousatrd d()llars ($100,0()()), in addition to thc cost of comlEnsation, daMgcs as providcd lbr thc <br />Scctkn 3076 of thc htx)r Codc, intcrcst {nd sttonEy's fccs. <br />n"r.,4.- 8-21 Appscanr: HOYlbi LObol <br />, <br />DECLARATION <br />I hcrcby allirm undcr pcnalty of'Jrcr.iury that I anr liccnscd under pn)vision of Chaptcr 9 (commcncing with Scclion 7fiX)) of Division -] <br />ol' thc Busincss anrl Pnrl'cssions Codc, and my liccnsc is in lull lirrcc and cll'cct. <br />W <br />I hcrchy aflirm undcr lEnalty of lrcrjury that thcrc is a custructbn bnling agcncy for thc lErfomrec of the work for which this Ismit is <br />issucd (Se. 3097, Civ. C.). <br />lIndcr's Namc: <br />krttlcr's Addrcss: <br />APPLICANT DECLARATION <br />I hcrchy atlirm undcr pcnalty of pcrjury onc of thc folkrwing dcclarations: <br />Dcmolition Permits-Ashcstos Nolification Fcdcral Rcgulations (Titlc 40, Part6) <br />_Rcquircd lrttcr of Notificatirxr <br />_l ccrtily that thc l'cdcral rcgulations rcgarding asbcslos rcmovalarc not applicablc to this pnrjcct. <br />M..nity that I havc rcarl this applicatkrn arxl statc that thc ahrvc infrrrmation is corrcct. I agrcc lo comply with all City and County <br />turdinanccs and Statc [-aws rclating lo building construction. arxl hcrcby aut]xrrzc <br />atxlvc nrcntioncd propcrty lilr <br />Applicant or Agent <br />Pennitce nanre <br />purF)scs. <br />fr <br />of this City and County to enter u;nn thc <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenVl ns u lation <br />Roof Sheathinq <br />Shear Wall <br />Framing <br />!nsulati onlEnerqv <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />ltlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />t/ <br />FINAL Lltlltr JL 6U <br />Certificate of Occupancy T <br />Notes, Remarks, Etc. <br />Elarr n9,-n7 -2n 1 6 <br />/ <br />q4B \b5Liccttsc cr"rr' b Liccnse Numbcr: <br />,,*, ?'-B--2t conrracro, l+"bV t bh/ <br />**,?{,'1.1