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OIVNIiR RUILDI]R DI]I-CARA'TIoN <br />I hcrchy alfirilr undcr pcnrhy of pcrjury that I anr cxcmPt from thc Contraclors' l-iccnsc Law li)r thc {i)lk)wiDg rcr\on lScc.70-]1.5 <br />Rusincss and Prolcssion Codc): Any City or Counly which rcquircs a lErnril lo construcl. allcr. inrprovc. dcnrlish or rcpair any <br />slruclurc. prior lo ils issuilncc. also rcquires thc applictrDl for such Jrrtrril lo lilc u \igrrcd \tiltcnrcnt thrt lE or shc i\ liuc[\cd pursurnl <br />k) thc fiovisions of thc Conlraclor's l,iccnsctl hw (Chaptcr 9. Conurcncing with Scclior 7(XX) ('l lfcli()r}.J^l5 l]usiness and <br />Prolcssions Codc) or thar lr or shc is cxcirpt thcrclionr and thc busi\ li)r lhc rllcgcd c\cillrlion. Any violxriol ofScclioi 70]1.5 by rny <br />applicantforapcrllitsuhjcctsthc applicanrtoacivilpcnxllyofnoto(,rcthrnfilchundrcdd(,ll^rs(15{x)).-i> <br />I. r\ owilcr (,1'thc p()JEily. (n rry cillnkryccs with wagcr rs thcir solc errnrlrcnsltiorr. uill (k, tnt'iv(nk ilrtrl the \tnr(turc i\ rxrt <br />lhcpn)Fny lvhobuildsorirnprovcsthcrd)n.udwhodocssuchuorkhinlsclforhcrscllorlhroughhisrrrhcrownerrrpkryccs. <br />providcdthatsuch inrprovcrre[tsarcnolililcrdcdorolllrcdlbrsrlc.ll.ho$cvcr.lhchuil(lingorirnprclcilrntissoldwithin(!r]ril <br />ofconlhtion. thc Owncr Builder will lHvc lhe burdcn of provi[g that lE or shc did not huikl or inrprovc thc p()Ircfly for thc purF)* of <br />salc ). <br />l. rs owncr ol thc prol)crly. am cxcltlsivcly conlrncling wilh liccn\cd cornr ack)rs l(, con\lnlcl lhc prrjccl (Scc. 7().11. Ilu\irc\s <br />ilnd who contrrcts I'or such pr()jccls wilh a Conlrilckrr(\)pursuant lo lhe Conlrack)as Licclsc l.aw). <br />I hcrcby al l irnr undcr pcnxlty of pcrjury onc of lhc li)llowinS dcchration\: <br />_l hilvc end will nuintain u Ccrlilicrlc ol Consenl lo Scll:ltsurc iif w(tkcrs' coilpcnsilion. as pr(,vidcd li,r hy Scclir)n .17(X) of lhc <br />[-atx)r (i)dc. tbr thc pcrloronDcc oflhc work for which lhc pcrmit is is\uc(|. <br />_lhrvcandwillnraintxinworkcn conrpcnsatio[insurancc.as rcquircdhyScction.l?(x)o[thcLahorCodc.lbrlhcpcrli)rnunceof <br />thc work ti)r which lhis pcrmil is issucd- My workcrs' coDfcnsalion insurtrncc caricr rnd F)licy nurnbcr rrc: <br />Policy <br />-l <br />ccnify that i[ lhc pcrli)rmancc ollhc work lin which this permit is issucd. I shnll trot cil]pk)y otry pcrsotr in any rnxnncr <br />so rs k) bccotrrc suhiccl lo lhe workcrs'cotrrpcnsalion hws ofCalilornin. and flgrcc thal il l should hccoilrc srhjcct h lhc <br />workcrs'conrpcnsrttnrprovisionsolSccli()i.17(X)ollhclahorCotlc.lshall.fonhwithconlPlywilhthoscprovisk]il <br />WARNING: Failurc lo *curc workcrs compcnsrlion covcrrgc is unlur'lil. and \hrll suh.i('cl an cmpk)ycr to crinrirtrl Jtilaltics and <br />civil ines up to ooe hundred thousanrl dollus tn cosl ol'ion.lor <br />Sccri(,n .1076 otc Lafr Codc. intcrcst <br />D,r", - n ]!7D tt - <br />ilil(l rlk)r,rcy'( <br />Applicanl: <br />damges as providcd <br />I hcrchy allirnr undcr pcnally of pcrjury thal I ant liccnrtl undcr provi\ion ofChaflcr g (conurnncing with Sccti{)n 7(Xx)) ol I <br />ol' lhc Rilsincss trDd Prrfcssions Codc. and my liccnsc is iil lill li)rcc atr(l cllcct. <br />Liccnsc Class:-Liccnsc Numhcr: <br />Dsle: Contmclor: <br />CONSTRUCTION LENDING AGENCY <br />I hcrchy affirm undcr pnally of perjury that there is a conslrucliril hnding rgcncy lbr thc [rcrfornEncc of thc work for s,hich lhis fErmit is <br />issucd (Scc. 3097. Civ. C.). <br />Lender's Namcl <br />[-cndcr's Addrcss: <br />APPLICANT ITECLARATION <br />I lErcby nflim undcr pcnalty of pcrjury onc of lhc folhwi0g dcclaratiols: <br />Dcrnolilion Permils-Asbcslos Notificalion Fcderal Rcgulnlions ('l illc 4{). Pnrl6) <br />_Rcquircd kllcr of Notilication <br />_l .cnily thill lhc lcdcrnl regulati(ills rcgiudirg rshc\los rcrnovillnrc n(il applicahlc kr Ihis projcct- <br />-l <br />ccl1ily lhat I hrvc rcad lhis appliculior alNvc iIlinrnxti()n <br />ordinrnccs and Statc Lrss <br />wilh all Cily ilod County <br />irnd <br />Tunty <br />t) cnl$ unon thc <br />rbtf ^ :t <br />hril(l and <br />atx)ve ntf,lioncd propcrly for ion <br />Appli($nt or Agent <br />l'crnrilm trntrlr (pritrl): <br />l)lrJ- <br />SITE-WORK DATE ID/SIG.COMMENTS <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVl nsulation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Reo <br />Deputy Final Report <br />Enqineer Final Report <br />Flobd Zone Certif <br />lfl lr I <br />FINAL fi 4'/-/,2 /l/,(al Uclt Y <br />Certificate of Occupancv 'l I <br />Notes, Remarks, Etc t,/ <br />BUILDING. INSPECTOR RECORD <br />1-0rLI)tlr