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BUILDING- INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG COMMENTS Owncr.Buildcr Dcclrrarion <br />I hcrcby aflim undcr p.nalty ol pcrjury thd I or cxcmpt fmr thc Contr&tos' Liccnsc Law for thc following rcuon (scc 7031 5 Busincss <br />udProtcrsion(ixJcl AnyCityorCounrywhichrcquircsapcmittoconstrucl,altcr,improvc,dcnrolishorrcptirmystructurc,pnortotls <br />issuocc,alsorcquircthcrpplicutforsuchpcrnrittolilcasigncdsldmcnl thdhcorshcisliccnscd puEuoltolhcprovisiorrofrhc <br />Conl.acto.'t Liccnscd Law (Choptcr 9, Comcncing with Scction T0OO of Drvision I of thc Busrncss urd Profcssrons Codc) or that hc or <br />shc is cxcnrpt thcrcliom ud thc b6is fq thc rllcScd crcmption Any violarioo ofScction 703 I 5 by my applicel fu a pcmir subjccB rhc <br />rpplicut lo a civrl p<nalty of nd mr. thm fivc hun&cd dollm (S500). <br />-1, <br />u owncr o[ thc propcny. or my cnrployce with wagc u ticir rolc cornlmsation. will do rhc wor k ud thc structuc is nor rnrcndcdu offcrcd fa salc ( Ss 7(N4, Busins Md Prcfc$ims Codc. Thc Conu&tor's Liccnsc Law dfts nor apply to u owncr ofthc propcny <br />who burlJs or rnrpovcs lhcr con, ud who dm such wort himsclfq hc6clf u thr@th his r hcr own crnployccs, p.ovidcd rhar 5uch <br />improv.trEnBucnolintcn&doroffacdfqralc lf,hovcver.thcboildingorimprovcrnentissoldwithinoncycilofconrplctiorr,thc <br />Owncr-Buil&r wrll havc thc b{rdcn of proving thil hc q shc not build or improvc for thc purposc ofstlc) <br />_1, s owns of fic propcny. m cxclsrvcly @ntEting wilh licscd conrractor to coutrucr lhc proJcct ( Scc. 7044, B6incss ild <br />Profcssion Codc The Contrrctor's Liccnsc Law du not apply to u owncr of propcny who builds q improvcs thcrcon , Md who <br />cqtrrb fq such projccs wirh a Cutnctq(s) Iicffid FEuut to thc Contracta's Liccnr Law ). <br />_l m cxmpt undcr Setion & P C fo $is rcuon. <br />Dolc: O*nd: <br />I hocby afiim undcr <br />WORhTRS COMPENSATION Dt:CLAR,lTION <br />onc of thc following delsdi@s: <br />_l havc ud aCcnificatcofCoscnttoSclf-lnsurcforworkcG'compcnsrtion,ro provrdcdforbyScctionJTOoofthc <br />Labor thc pcrfmcc of thc wqk fq which thc pcmit ir isucd <br />for <br />ud will ruinmin wskcs' cmp<roaliorr insuroe, q rcquircd by Scctio 3700 of $c Lahx Codc. for $c [Erfomcc of rhc <br />which this lrmil is issucd My workn' cmpcnsalion insurecc curia md gtlicy numbcr uc. <br />f,il". <br />Policy Numbq, __Erpircs: <br />(This scction nccd nd bc complcrcd if thc Fdnir is fq Onc hundrcd dollc l$ l0Ol a lc5s) <br />-l <br />c€nify that in thc pqfmucc of thc worl for *hich thir pmit is i$ucd, I shall not cmploy oy ;mm in my mncr so u ro <br />lxe mc 5ulUccl 1., lh€ t,,r lcr r ' e orrlxns.,tion lrs r of ( rlifmra, ud atre thdt if I chould b.comc subjcct to rhc workc6' <br />comlEnsation of Sstion .]70O of fic Codc, I shall, frthwith comply wirh thoc provisions. <br />WARNINC Failurc to sccurc workc[' compcrottid <br />finc up lo onc hundrcd thousd doll6 (5100,000),in <br />tlrc Lubor ( ulc. ilrlcrusl iltJ Jttorilcy's fcci <br />is unlawful, orrl shall subJcct U cmployc, to criminal ;xilaltics md civil <br />to thc cs1 of compcosation. dmagcs 6 providcd ftr $c Scction 1076 of <br />LICENSED CONTRACTORS DT:CLARA I ION <br />I hcrcby alllm undcr pcndty of pcrjury Lhrt I m liccnscd udcr provision of Chapta 9 (commncing wirh Scclion 70OO) of Division .l of <br />lhc Busincls md Prollslioni Codc, ud my liccnrc is in full fqcc od cffcct <br />Limsc Clcs Liccnsc <br />Datcl <br />I hcrcby allim undcr pcnalty of pcrjury thal th6c <br />isucd(Scc 3097.Civ C) <br />Lcndcr's Nmc. <br />aScncy thc lrcrfoniucc ol lhc work lbr which this p€nnit i! <br />Lcndcr's Addrcss <br />tlcmolirion <br />APPI,ICANT'S DECI,AITATION <br />Notil'icdion Fcdcral Rcguldies (Tiilc 40, Pd 6) <br />Lcscr of Notil'icati()n <br />_l that thc fcdcral rctulrtions rcguding obctc rcmoval re not applicablc to thir projcer. <br />'thd I hlvc rcod this application od statc that thc abovc infmation is conccr I tgrcc toccni fy conrply with rllCity ud Couory <br />ud Slrrc Laws rclatinS to building coostructiq, ud h@by ufioria rcpr6.ntlrivd of lhis Ciry ud County ro ctrtcr upon thc <br />abovc mcntimcd propcny for 62 2/e rApplicet o. a8cn( <br />Pcmitt.c rerc (p rrl) <br />7 <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />SubfloorA/enUlnsul <br />Roof Sheathing '* - 1/'et t <br />Shear Wall I <br />Framing <br />lnsulation/Energy <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 />Engineer Final Report <br />FINAL ff1 '/l-DI litlLl[1T IJ,S otr SN.N VV <br />Certificate of Occupancy I r <br />Notes, Remarks, Etc. <br />/xt