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BUILDING. INSPECTOR RECORD <br />SITE.WOHK DATE ID/SIG.COMMENTS ()}VNI]R BT'II,I)ER DEI,CARATION <br />I hcrchy rllirnr undcr pcilrlty of pcrjury lhal I rn! crcmpl liofi lhc (i)trlrxctor(' l-iccnsc l.aw lilr lhc ti)lk)wirc rcason (Scc.7().11i <br />Rusrncss nnd l)rotir(siril Codc): ADy City r)r Counly whrch rcquircs n JErmil lo coil\lnrel. rltcr. improvc. dcmolish or rcpair any <br />slnrcllfc.l)r(]rk)rlr r\suaDcc,alsorcquircslhcapplicunllorsurhlErmiltolilcasign!'dslntcnrcnl lhalhcorshcisliccnsc(l pursunnl <br />k) thc pr)vi\!)[s ol lhc (i)nlra(k)r's Licenscd l-aw (Chaplct 9. Crrnmcncinc with Scclion 7fiX) ol Divrsion .] o[ thc BusiDcss ird <br />rpplicrnt tix r Nflnil suhjcets lhc applic.nl k) r civil lcnally ol nol morc thail l'ivc hurdrcd rkrllars ($5{)0). <br />_1. n\ owlcr ol'thc p()lEfl y, ()r rly cnlpl()yccs wilh wagcs as I hcir solt' conrJtnsrl irtn. will do lhc work uil thc slructurc r\ nril <br />uicndcd or ollcrcd lir salc (Scc.?044, Bu\incrs and Prolessioni (ixlcr 'l he Contrrctor's Liccnsc Law dr)cs not alply k) in owncr ol' <br />thclr)ltrty whohuildsorirnprovcslhcrqnr,inJwhod(rcssuehw(nthinlscll'orhcrscll'()rlh(Nlhhisorhcr()wncnrlh)yccs. <br />providcd thll such imfrovcnrcnts rrc nol intcndc(l orolltrcd ti)r salc. ll, howcvcr, tlc httiklirrs or inrprovcrrnt iq sold wilhil onc ycar <br />salc). <br />_1. !s r)wncr ol lhc Jrr)l)crly. rnl cxcfu\ivcly c()nlrrctinf, wilh liccns&l crnilricl)rs tr (on\lnrct lle pr(tcct (Scc. 7(H4. Itil\tr)cs\ <br />anJ ['nrlissirnCodc:'lhcC()nlracl{)r'sLiccnscl.rwdocsroldpl)lyk)anowncrr)lfi)pertywhohuilds()rinllrovcslhcrcon. <br />anrl who c()nlrrcl( li)r such projccts wilh r Corilrrcltr(s) liccnscd pulsuant lo lhc Ci)Dlrrel(,r's I-iccnsc I-rw). <br />-Iamcxon|tUndcrScCli()n-.B.&P.C.li)rthisrca\on <br />\\'oRKIatrs' ( ()l\il't,.Ns^t toN <br />t)ta('1.,\ttA't't( )N <br />I h('rchy rllrfln und(-r pcnrlly ol N4ury onc ol lhc li)ll)wirr! (lcchrxlion\: <br />_lhavcilxlwillmaintrinaCcrlilicalcofCrlnscDtloScll:lnsurclirrworkcrs conlrcrsrlion,ns proviilcdfi)rhySceti()n.l7U)otthc <br />I-itx,r Cirlc. lilr thc pcrl'r)rmance oilhc work lbr which lhc fcrmil i\ irsucil. <br />thc w(xk lilr whrch thrs pcrnlit is issucd. My workcrs c()nrpcnsrlirnr in\uranrc catricr dRl F)licy rnrnlhcr [c: <br />Poliuy Nrrnrhcr:_Erpircs: _ <br />__l ccrlily lhrl irr thc pcrli)rnrinc(' ol lhc wr)rk liil' which lhrs Frmil i\ issucd. l (hrll nol cnrpl)y lny pcrK)n irr any nritncr <br />so ds k) tf,.c()mc slrbject lo lhc workcr\'conlpcn{xli(,n hws ol'Cllil'()rnia. {nd rtrcc thrt il I should hcc(nlE snhjcct k) lhc <br />wo*cr\'crnnltn\{tirrrpr)vi(ionsofSecli(rr.}700oithcl,alx)rCodc.lshrll.l(nlhwithconrnlywilhthoscpRrvisions. <br />civil lint's up lo oN- hunJrcil lhrnrsand dolhn (5jl x(ldili(rr lo lhc compcnsalion. danngcs as Fovidcd tbr lhc <br />Scctir)n -1{)7(r ol thc lrlx)r C(xlc. illcrcst nnd <br />I hcrcby all'rrnr undcr pcnrlty of l^-rjury lhal I unr liccnscd under provisi(D ol Chiplcr I (cornnEncirg with Scct(i 7UX)) ot Divisii -l <br />ol' lhc llrsircss rnd Prolcssions Ctxlc, rml my liccnsc is ir htll lirrcc oxl clltct. <br />l,i(cnsc (tt6 Numlrcr:G \-4 e/ <br />I ( <br />( A.^ <br />I hqL.tty rllirm urrd('r p!ilrlty ol I^*{ury lhat <br />i\sucd (Scc. l(197. Civ. C.). <br />aconslnrclionkndinralcncvti)rlhcpcrli)rrnrnccoflhcworktirrwhiehthisfxrtrlil is <br />l-cnrlcr's Nanrc: _ <br />l,cndtr"s Ad,lrcss: <br />APPI,I(:ANT DECLARATION <br />I lrrthy allimr undcr pcnalty ol pcrjury rnc t)l lhc li,llowinL dcclrral ions: <br />I)curlition Pcrnrls-Ashcqk)s Noliflcillirr F('dcral Rcgulali(ilr\ ( l illc 40. Parl6) <br />__Ru;uuett l,(tlcr ()l Nottlieilti(nl <br />lhi\ pr(t('cl. <br />I ngrcc k) comlly wilh ill City and Cr[nty <br />ivcs of lhi\ Cit y ilnd Counly to cntcr uF)n thc <br />Itcrillilce <br />2< -/7 <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVl nsulation <br />Roof Sheathino <br />Shear Wall <br />Framinq <br />lnsulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />FINAL Vhil/a t aL,^ -A^ a ,lfg ) <br />Certificate of Oc <br />Notes, Remarks, Etc <br />,r^,". t( '25' l)11