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BUILD!NG. !NSPECTOR RECORD 1r> <br />Bev.08-07-2015 <br />SITE.WORK DATE ID/SIG COMMENTS owNlr,R llt,ll,l)t:L t)l.rr,cARA'rroN <br />IherebyaffirnrundcrpenaltyofpcrjurythatImretenrplfronrtheClontracloB Liccnsebwforthefollowingrcasn(Se.7031.5 <br />Business and Prolcssion Codc): Any City or County which requircs a 1*rmil lo con$lnrct, altcr. irnprove, dcrrelish or rupair any <br />stntcture. prior b its issuance. illso requires the applicant tbr such pemrit t, lilc a signed slatemenl lhat he or she is licensed pursuaill <br />lo lhc lrovisions of rhc Conlracrcr's l-iccnscd Iiw (Chdpter 9, Commencing wilh Scction 7fiil ol l)ivision 3 of the Business and <br />P(r'essioDsCqle)(trlhatheor{heisexempttherefiomaBlthebasi\forthealleSedexenrptiorr. AnyviolatiooofseclionT0Sl.5byany <br />tpplicint[orrpennitsubjectslhc npplicnnttorcivilpenxltyofnolmorethanllvehundreddollnrs($5(n). <br />_1, as owncr ol lhc prolEny, or my crnployccs wilh wagcs as lhcir $lc compcnsation, will do lhc wo* ard the stMtue is mt <br />inenled or offered for sle (Se.7{}14, Business and Pnrfcssions Crxle: The Contractor's l-iccnsc l*w rlocs nol apply lo an owncr of <br />lhepropeny whobuildsorimproveslherenr,andwlrcdoessuchworkhimselforhersclforlhrouShhisorherowtremployees, <br />providcd thal such improvemnts dc not intcnded or ollercd I'or slc. ll, howev!'r, lhe building or improvcmnl is sob within one ,rar <br />ofconplelinr, thc Owrer Buiucr will lmve the burden of provinB llw lrc or she did mt boikl or impmve th6 prcpeiy for the purF)s of <br />$le). <br />_1. ns ownlT oflhe lroperly. anr cxclusively contracting wilh Iicenscd conlrnclors to conslrucl llE prcjeet (Sec. 7{}14. Business <br />arxl PnrlissirrCorle:'lheContructor'sLicerrse[-awrloesnotapplybailowilcrofpropcnywhobuildsorinrprovcsthereotr. <br />and who contrnctsforsuchprolcctswirhrContrach(s)liccnscdpursunnlhlhcCoolraclor'sLiccnscLaw). <br />-l <br />anlerempt under Section-, B. & P.C. lbr this rearon. <br />WORKI]RS' COM PI]NSATION <br />DECLARATI0N <br />I hercby all'irm uodcr pcnalty ofpcrjury one oflhe tblhwing dccluarioN: <br />_lhaveudwill MintainaCcrtilicateofConsentroSelFlnsureforworkeK'compensation,as prcvidedforbyS€ctionS?00ofthe <br />tihor CgMor thc Frrlorrumc of lhc work for which thc pomir ir isrucd <br />!#an,lwillmaintainworkcn compcnsalioninsurancc,as requiredbySection3TOOofthekborCodc,forthcperformrceof <br />ilc work t'rrr which this f{rmir is ilsucd. My workers' q)mpcruation insurunic cmier unl grlicy numbcr ue: <br />canrer: 9lz+n 1- 7-n \ . <br />Policy t)l-L-zz-zo <br />_l ccfify that in thc Frfornrnncc of thc work for which this lrc(nrit is issucd. I shall not cmploy any Prson in any muncr <br />so a s to hcco nrc subjcct to thc workc6' co nrpcnsat ioD lawr o f Crl i lbrtria, aDd 18 rcc thxt i l l should bcco rru subjccl to the <br />workers'conqrnsationprovision$ofSectionST00ofthel-aborCode,lshall,fonhwithconrplywillrtho*provisions. <br />WARNINC: Failurc h sccurc workcrs'conrpcnsrtion covcrngc i\ unlawful. and shxll suhjcct an cnrlroycr t| fiminll lrelix md <br />civil fincs up to onc hundr.d thoussnd dolhrs (SI(X),(Xx)), in rdditioD to lhe cosl ofconrpensation, damnees $ provided for th. <br />Sccliotr .](176 ofthe l-atx)r (ixle. irilerest and attomev s feer. /'1 <br />=,/l /// __-L-71-zo <br />I,ICENSED CONTR (]TOR <br />DEEIAEAIIAN <br />I hereby allirm under pcnally of pcrjury that I am liccnd under provision ol Chaprer I (comrrencinS wilh Section 7000) ol Division 3 <br />of rhc Busincss and Pft)fessions Codc. ml mv liccnsc is in full lbrcc and clfcct. <br />[-iccnsc t--o <br />u^,", Z'21'7 ) <br />@ <br />I hercby a|irm ullder lEnaltyof perjury that there is a conslnrction lerdhg aSeDcy fbr the perfomnce of the work for which rhis pemrit is <br />issued (Scc. 1097, Civ. C.). <br />[4ndcr's NanE. <br />L(.ndcr's Ad(lrc\s: _ <br />APPLICANT DECLAR.ATION <br />I herebyuffmrunder p€nalty ofperjury one ofthe following declarations: <br />Dcnelition Permils-Asbestos Notification Fcderal Regulations (Title,l0. Part6) <br />_Required bttcr of Norificalion <br />_l ceaify rhat re!ilditrg nshcslos renroval are not ill)l)licahle k) this proicct. <br />with rll City and County <br />a[d County to entcr ulpn (lE <br />iltx)vc mnti()ncd propcf,y lbr <br />Applicant or Agcnt <br />l'(mrile( nanrr <br />,Lr. Z-7 L- ILr' <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenUl nsu lation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulationi Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />[t/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputv Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />li <br />FINAL 4//2,'7.O /l*Ycil / <br />Certificate of Occu <br />Notes, Remarks, Etc. <br />/oo Yos -