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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG COMMENTS OWNER BUTLDER DELCARATION <br />I hcrcby arlirm utrdcr Fnaly of lErjury thal I am cxcmpt liom lhc Contrachrs' Liccns hw for thc li)llowing rca*rn (Ss.4ll.s <br />Busincsr ?nd Profcssion C(xlc): Any CiIy or County which requircs a Jrmit k, construct. alts, improvc. dcmrlish or rcpair any <br />struclurc, [rx)r to its issuancc, also rcquircs lhc applicant for such Frmit k] filc a signcd slatcmnt that hc or slE is liccn$d pursuant <br />k) lhc E()visi()ns of thc Contracl()r's Liccnrcd taw (Chaptcr 9. Commncing with Scction 7000 ot Division .l (!f thc Busincss and <br />Pnllcrsk)n$C(xlc)orthalhcorshciscxcmptthdchom.ndlhchasisforthcallcgcdcxcmplion, AnyviolationofSetionT0ll.5byany <br />applicaDt li)r a fErmit subjets thc al,plicanl to a civil pcmlty of not mrc than five hundrcd dollas ($500). <br />--1, as owncr of thc propcrty, or my cmployccs with wagcs as thcir solc compcnsation. will do thc work aftl lhc strur,*turc is not <br />intcrxlcd or oll'crcd lbr salc (Scc.7044. Business and Prot'cssions Ctxlc: Thc Glntractor's License law dtrcs not apply to an owncr of <br />thc pnrJrcrty wlxl builds or imprrtvcs thcrcon, anl who tltrs such work himsclf rtr hcrsclf or through his or hcr own cmpkryccs, <br />provitlcd that such impnrvcnrcnts arc not intcrxlcd or oft'crcd tirr sah. It. txlwevcr, thc building or improvcrncnt is sokl within onc ycar <br />ol'complction. tltc Owtter Buildcr will havc thc burden ol'pnlving that hc or shc did not builtl or improve thc proJrcrty lirr thc purJxlse ol' <br />salc). <br />_1. as owncr ol'lhc property, ant cxclusivcly contracting with liccnscd contractors lo construct tlrc projcct (Scc. 7044, Busincss <br />arx.l Pnrtbsskrn Codc: Thc Contraclor's l-icense Law docs not apply to an owncr of progrcrty who builds rlr improvcs thcrcon, <br />and who conlracts tor such projccts with a Contraclrlr(s) liccnscd pursuant to thc Contraclor's Liccnsc Law). <br />-IamexcmptundcrScction-.B,&P.C.tbrthisreastln. <br />WORKERS' COI\T PENSATION <br />DECLAITATION <br />I hcrchy al'llrm undcr pcnalty ol'prjury onc of thc tillkrwing dcclarations: <br />_l havc arxJ will maintain a Ccrtilicatc of Consent to Scll-lnsurc tbr workcrs' comJrcnsation, as pr<rvidctl lirr by Scction 3700 of thc <br />Latxlr Crxlc, tor thc Jrcrtirrmancc of thc work tbr which thc pcrmit Ls issued. <br />_.l havc and will maintain workcrs'comlrcnsation insurancc, as rcquired by Scctiun -]700 of thc Labor Codc, tirr thc lrcrlirrmancc o[ <br />thc wrlrk tilr which this ;rcrmit is issucd. My workers' conllrcnsation insurance carricr and Jxllicy numbcr arc: <br />s <br />Policy -,0--l-zl <br />_l ccrlily that in the Jrcrlirrmancc o[the Work tbr which this Jrcrmit is issucd, I shall mrt cmphly any lrcrson in any manncr <br />so as lo hcconrc subject to thc workcrs' compcnsation laws of Calililrnia, and agrec that if I should bec<lmc subjcct to thc <br />wrlrkcrs' conrJrcnsation pnlvisions of Scction 3700 of thc Lahlr Crilc, I shall, lirrrhwith comply with thttsc pnrvisions. <br />WARNING: lrarlurc to sccure workcrs' conrJrcnsation covcragc antl shall subjcct an cnrploycr to criminal Jrcnaltics and <br />civil lirrcs up to onc hundrctl thousarrd dollars in lo thc cosl ol'cornlrcnsation, damagcs as providcd tirr thc <br />Scclion -1076 of'thc Labor Ctxlc. intcrest and attonrcy's <br />p"6, .3- lO-Z( <br />I hercby allirnr under Jrcnalty of pcrjury that I am liccnscd undcr provision of Chaptcr t) (commcncing with Scction 7UX)) of Division 3 <br />ol' thc liusiness and Pnrl'cssions C<xlc, anrl my licensc is in lull lorcc and cfi'cct. <br />Liccnsc a 4s Esr.,(frla <br />,^*, o'1 "10 *Zl <br />w r <br />I hcrcby allirm undcr penalty of Frjury that therc is a coDstruction btrding agency for thc Jrcrfomrcc of thc work for wbsh this Ismit is <br />issucd (Scc. 3097, Civ. C.). <br />lrndcr's Namc: <br />hndcr's Addrcss: <br />APPLICANT DECLARATION <br />I hcrcby allirm undcr pcnalty of Jrcrjury onc of thc firllowing dcclaratkrns: <br />Dcmolition Pcrmits-Asbcstos Notillcation Fcdcral Regulations (Titlc 40, Part6) <br />_Rcquircd lrtter of Notilication <br />_l ccrtily that the l'cdcral regulations rcgarding asbcstos rcmoval arc not applicablc to this projcct. <br />mk.",aity that I havc rcarl this application uxl state that thc atxrve intbrmation is corrcct. I agrec to comply with all City anrt County <br />rlrriinanccs and Statc Laws rclating to arxl hcrchy authorizc rcprcscntativcs of this City and County to entcr u;xln thc <br />atxrvc mcntioncd proprty ti)r <br />Aliplicarrl or Agenl <br />I)crrttilcc ttanrc <br />ortu, --blFZl <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenVl nsu lation <br />Roof Sheathing <br />Shear Wal! <br />Framinq <br />lnsu lation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Jt/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Fina! Report <br />Flood Zone Certif <br />tl <br />FINAL 'llt ftt \K yz <br />Certificate of Occupancy tt <br />Notes, Remarks, Etc. <br />) <br />Florr nP*n7 -2nl q <br />f \.-. ,.. <br />a <br />a