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BUILDING. INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby affirm undcr Jrcnalty of pcrjury that I am cxcmpt lmm thc Contrilclos' Liccnsc tjw for lhc following rcamn fS6.70.}1.5 <br />Busincss and Profcssion Codc): Any City or County which rcquircs a lEmit lo construct. altcr. improvc, dcmlish or rcpair any ' <br />structurc. pdor lo its issuancc. als rcquircs thc applicanl for such JrcrNit lo lilc o signcd statcmnt that hc or shc is liccnsd pusuanl <br />to thc pmvisions of lhc Conrrrctor's Liccnmd law (Chapter 9. Commcncing with Selion 7000 of Division 3 of lhc Busincss and <br />Pmfcssions Codc) or that hc or sh€ is cxempt Ihcrcfiom and tlrc basis for lhc alhgcd cxcmption. Any violalion of Satbn ?03 | .5 by any <br />applicnnt for d pcrmit subjccts the applicant to a civil pcnalty of not morc than fivc hundrcd dollars ($500). <br />_1. as owncr of thc propcrty, or tny entployccs with wages as thcir solc compcnsation. will do thc work ald thc structurc Ls not <br />intended or ofl'crcd tbr sale (Scc.70++. Busincss and hof'cssions Codc: The Contraclor's Liccnsc Law docs not apply lo an owncr of <br />the propcrty who builds or improves thcrcon. and who does such work hinrsclf or hcrsclf or through his or hcr own cnrployecs, <br />providcd that such improvcrrrcnts iue not intcndcd or oflercd tbr sah. If. howcver. thc building or inrprovenrcnt is sold within onc ycar <br />of cornphtion. thc Owncr Buildcr will havc thc burdcn of proving that he or shc did not build or irnprove thc propctty for thc purpsc of <br />salc). <br />-1. <br />as owncr of thc proprty. am cxclusivcly contracting with liccnscd conlractors to construct thc projcct (Scc. 7U4, Busincss <br />and Pmfcssion Codc: Thc Contractor's Liccnse Law does not apply to an owncr of propcrty who builds or improvcs thcrcon. <br />and who contracts for such projccls with a Conlractor(s) liccnscd pursuant to thc Contractor's Liccnsc Law). <br />-lamcxemptundcrScction-'B.&P.C.forthisrcason.Dale: Owner:_ <br />WORKERS' COM PI.'NSATION <br />DECLARATION <br />I hcrcby affirm undcr pcnalty of pcrjury onc of thc following dcclarations: <br />_l have and will rnaintain a Ccrtificatc of Conscnt to Sclf-lnsurc for workcrs'compcnsalion. as provided for by.Section 3700 of the <br />l:txrr Code, frrr thc lrcrformancc of thc work for which thc prmit is issucd. <br />-l <br />havc and will rnaintain workcrs' compcnsation insurancc. as requircd by Scction 3700 of thc labor Codc. for thc pcrfornuncc of <br />thc work for which this pcrnrit is issucd. My workcrs' corngrcnsation insurancc carricr and plicy numbcr arc: <br />F.),UD P9,tW oF <br />Policy t <br />-l <br />ccrlify that in thc pcrlbrrrrancc of thc work tor which this pcrrnit is issucd, I shall not employ any pcrson in any munncr <br />so as lo bcconrc subjcct to thc workers' conrpensation laws of Calitbrnia. and agrcc lhat if I should bcconrc subjccl to thc <br />workcrs' conrpcnsation provisions of Scction 3700 of thc l,irbor Code. I shall. forthwith cornply with thosc provisions. <br />WARNING: Failurc to sccurc workcrs'compcnsation covcragc is unlawful. and shall subject an empl<lycr to crirninal pcnaltics and <br />civil fincs up to onc hundrcd thousand dollars ($100.000). in addition to thc cost of conrpcnsation. darnages as providcd for thc <br />Scctiorr ol'lhc t abor Codc, intcrcst and atlorncv^'s fccs. <br />ArrlxU <br />r r CENS r,'t ) C( rN't'Br(-Tir R <br />DI.'CLAIT,\'TION <br />I hercby affrm under penalty of pcrjury that I am liccnscd undcr provision of Chaptcr 9 (commcncing with Section 7000) of Division 3 <br />of thc Busincss and Profcssions Codc, and my liccnsc is in full force and cffcct. <br />,1u3a"3LiccnscNurnbcr: <br />W <br />I hcrcby afftrm undcr penalty of perjury that thcrc is a @nstructk n lcnding agcncy for thc pcrforrolcc of lhc work for which lhis lErmil is <br />issued (Se. 3097, Civ. C.). <br />Lcndcr's Narrtc: <br />l-cndcr's Addrcss: <br />APPLICANT DECI ARATION <br />I hcrcby affmn undcr pcnalty of Jrcrjury onc of thc following dcclarations: <br />Dcmolition Pcrmits-Asbestos Notification Fcdcral Regulations (Titlc 40, Part6) <br />-Rcquired <br />lrttcr of Notification <br />X I ccrrify that the fcdcral regulations rcgarding asbcstos removalarc not applicablc ro this project.o <br />_l ccrtity that I havc rcad this application and statc that the atxrvc infornution is correcl. I agrcc to comply <br />rcprcscntativcs of this City <br />with all City and County <br />and County to entcr uJnn thcordinanccs and Statc laws rclating to construction. and hcrcby authorizc <br />above nrcnlioncd propcrty for <br />Applicant or Agenl <br />l)ernrilce nunro L,)'r'V <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf !oor/Ve nt/l ns u I atio n <br />Roof Sheathing <br />Shear Wall <br />Framinq <br />Insulatio nlEnergy ,I <br />Drywall v 1 WW <br />Ext./lnt. Lath \/ <br />Brown Coat <br />[\/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif. <br />I I -- <br />FINAL 7 <br />-{/ <br />J /,L UKV ;q <br />Certificate of Occupancv <br />Notes, Remarks, Etc. <br />a <br />Dare: ol nl et <br />a' <br />C