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BUILDING- INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG.COMMENTS OWNER, BTJILDEN DELCANATION <br />I hercby affrm undcr lrcnalty of lrcrjury thal I m ereDpt frcm thc ContrmtoB' Liccnre lrw for thc following u$n (Se.7031.5 <br />Business and Prcfession Codc): Any City or County whhh rcquircs r Fmit to mnstffL allcl irprcw. dcmlish or rcpoir oy <br />slrclurc, pri)r b ils issuam, also rcquircs the applicant for such trcmit to lilc I signcd statcmnt that he or slE k lien*d puNor <br />to thc provisions of tlE Contretor's Lhcnmd taw (Chaptcr 9, Commrcing with Setion 7000 of Division 3 of lhc Busircss ed <br />PmlbssionsCode)orthathcorshciscxcr{,tthercfromardthcbasisforthcalbgcdcxemplion. AnyviolationofSetionT03l.5bysy <br />applicsnt for a pemit sbjEts thc spplicant lo a civil p€mlty of nol rurc thil five hurdrcd dolles ($500). <br />_1. as owncr of thc propcrly. or nry cmployccs with wagcs as thcir solc compcnsillion. willdo the work and thc structurc is rx)t <br />inlcndcd or offcrcd for salc (Scc.7Ol4. Busincss and Professions Codc: J'hc Contractor's Licensc law docs not apply lo an owncr of <br />thc propcrty who builds or inrprovcs lhcrcon, and who docs such work hinmclf or hcrsclf <lr lhrough his or hcr own cmpkryccs. <br />providctl that such improvcnrcnls arc not intcndrxl oroflbrcd lbr sale. lf. howcvcr. thc buikling or inqrroverrrcnt is sold within onc )rear <br />trf contphtion. thc Owrcr Buildcr will havc thc burdcn of proving that hc or shc did not build or irnprovc the proprty lbr lhc purynsc of <br />salc). <br />_1. as owncr of the propcrty, am cxclusively contracting with licenscd contractors to construct thc proirct (Sec. 7W. Busittcss <br />and hotLssion Codc: Thc Contractor's Liccnse Law docs not apply to an owncr of property who builds or improves thercnon. <br />and who contracts for such projccts with a Contractor(s) Iiccnscd pursuant to thc Contraclor's License law). <br />-lamexemptunderSc.ction-,B.&P.C.forthisrcarcn. <br />WORKERS' COMPENSATION <br />DECLARATION <br />I hcreby aftlrrn under pcnalty of pcrjury one of thc fbllowing dcclarations: <br />_l havc and wrll maintain a Ccrtificalc of Conscnt to Self-lnsure for workcrs' comlrcnsation. as povided for by Scction 3700 of the <br />[:bor Codc. for thc pcrfornuncc of thc work for which the permit Ls issucrl. <br />_l have as requircd by Scction 3700 of the labor Code, for lhe ;rcrformance of <br />thc work tnsurancc c:uTrcr arxl nurnbcr <br />s3>4 C)}\Policy <br />__l cerrify that in thc pcrtirrnmncc of thc work for which this prmit is issuecl, I shall not crnploy any person in any nunncr <br />so as to bccomc subjcct to thc workcrs' compcnsation laws of Calif<lrnia, and agrcc that if I should bcconrc subjcct to thc <br />workcrs' compensation provisions of Scction 37CD of the Lrtnr Codc, I shall, frrrthwith cornply with thosc provisions.a <br />WARNING: Failure to sccurc workcrs'covcragc is unlawful. and shall subjcct an employcr to crirninal pc'3ltioc and <br />civil fines up to onc hundrcd thousand tll lo thc cost of compcnsation.il\providcd for thc <br />Scction 3076 of thc labor Codc, intcrest and <br />f <br />I)ale: <br />I hcrcby aflirm undcr pcnalty of pcrjury that I arn liccnscd provision of Chaptcr 9 (cornnrcncing with Scction 7000) of Division 3 <br />of thc Busrncss and Profcssions Codc. arxl my liccnsc is in full lbrcc arxl cft'cct. <br />t <br />Liccnsc <br />Date' <br />o <br />I hcrcby affm undcr lf,mlty of IErjury that thcrc is a @nsrudbn hndhS agcrcy for thc pcrf(m of the work for which this lEmit is <br />isscd (56. 3097, Civ. C.). <br />lrnder's Nam' <br />I-cndcr's Address: <br />APPLICANT DECI ARATION <br />I hcrcbyalilrmunder penalty ol'pcrjury onc of thc following declarations: <br />Dcrnolition Pcrmits-Asbcstos Notificatiorr F'cdcral Rcgulations (Title 40. Part6) <br />-Rcquircd <br />lrttcr of Notification <br />_l ccrtify that thc fcderalrcgulations rcgarding asbcstos renrovalare not applicablc to this projcrt.\ <br />__l ccrtity that I have read this application and state that the atnve information with all Cily and County <br />and County to enter upon the <br />(" ) ->l <br />ordinanccs and State laws rclating to <br />abovc rEntioncd properly for <br />Applicant or Agent <br />lDernrilee nanre <br />arxl <br />Datt*r_ <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenVl nsu Iatio n <br />Roof Sheathing <br />Shear Wall <br />Framinq <br />Insulatio nlEnerqy <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 />Enqineer Final Report <br />Elood Zone Certif tl / <br />fq*try^s Q/*/:t I Mtffia <br />\,//, ,f ,tl , <br />FINAL (7/8/4 t rtz,rud <br />Certificate of Occupancv <br />Notes, Remarks, Etc <br />Rev. 08-07-201 5 <br />I <br />I)ulr..Ormer:_ <br />t