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o\l'Nt R Dt[l,l)t.R l)]rL( ARA t ()N <br />to lhc fln\isions ofthc (.onlraclor's Licensed [-aN (('hapl$ 9. (bilrnreilcin8 \ith Scclion 7000 ofl)irisi()il 1 ofthe l]usiness and <br />.pplicant for a pcrilrit slbj{ts lhe afplicant to a cir il penalty ofnot rx)re lhan fi\'c huil(hcd (lollars ($50(l} <br />l.as orncrofthcproryny.ornryeilfkl)eesuilhsagcsaslhrirsolcconrpcnsaliur.sillrlothcrrorkaulthcstnrcllrcisn{)l <br />and $'ln) conlraclsforsuchpr()icctssilha(i)rnrnckn(s)liccnsc(lpursuailllollrc(oDtract(rr'sl-iccilsel-is') <br />rilder Sftti(nr <br />aso$ncrofthepropft.ame\clusi\elvconlraclin8\ilhliccnsc(lconlrrcloNlocorslrucllheprr)iect(Scc 701'l.l}isirrcss <br />l] & l'( lirrt <br />fru <br />DE('I,ARA'I'ION <br />I hoetry aflirrn under penaltl. ofpojurl one ofthe follon irrg delaratiors: <br />_lhavemdrill nraintaina('e(ificaleo[(i)nseillloSelf-lnsurefor\\l]rko's coirlensntbn..s pro\idc(l forlr)Sdlioil700ofthe <br />l-abor Corle. for the po fdrnance of Ihe rvork firr shich thc pornit is issuccl. <br />the trrrrk for uhich this permit is issucd. Nl! $orkqs c(nnfcnsali()n insurancc canicr antl Brlicr nunrbcr nrc: <br />(-an'icr <br />Nurnbcl <br />U-,lJL1 <br />I:\pir cs: <br />cffify thal in lhe perfornlance ofthe s'ork for shich this ptrmit is issrc(|. I shnll not employ anl poson in anr rranncr <br />so as to become sul)iecl to lhe wd'ko s' conrpensation laws of Cali fomin. and agrce I hat i f I should bcconre sul)iecl lo I hc <br />workos' conrpensaltrn pr ovisions o I Setion -1 700 of lhe l -f,txn Code. l shal l. fonh\r it h cotrrpl\ u'it h t hosc pr ovisirrs <br />WARNINC: Faihre k) *cure workers'coilpensalion coYemse is unlarvful. antl shall subject an enrphvcr to oirni[.] lu]alti6 and <br />ciril fines up to oile hundted thousntl dollars (Sl{}0.000). in addition to lhe cosl ,cortprrsation. darraccs as pror irlccl for the <br />Secti([ 3076 olthe t.al\n'(\xle. inlcrsl {nd allor nc!-s <br />,",". tlr, I tta <br />DECT"\RA'I'ION <br />I hcreby aflir rn undo penahy ofperjury that I am licensd under p[)r isiol of( haptr 9 (conrnrcncirrg r ilh Secliotr ?0(x)) of l)irision -] <br />of the Business and Profesions Code. and nry license is in full forte ancl effccl <br />License Class: <br />Drte: <br />Liccnse Nurnlxr: <br />I colify lhat the fcderal regulal ions regruding aslstos rerno\.al ar e nol alplical)lc to this fro.isl <br />cgtifl that I har e rcad lhis applicati()n aild slale lhat thc nlx)\ c in li)l nlal ion is cor r ecl. I arrr! lo c(rillpl! <br />( 0n(raclor: <br />CONS'I'RUC'I ION LENDIN(; AGTNCI' <br />I herctry allirm under penahy ofperjury that thse is a con$ruclirrr lmdirrg agency for the pofonrancc oflhe rrork for \ hich lhis pefinit is <br />issued (Sec. -1097. Civ. C.). <br />Lcnder's Nnme: <br />I-endcr's Addrss: <br />APPLICANT DECLAR IION <br />I ho-cby allinn under penalty of perjury one oflhc folkrrving declarrtions: <br />Demolition Pqrnits-Astmtos Notification Federal RCEUlatioils ( I ille 4(). Pai6) <br />Required l,ctts of Notifi calion <br />ao(l Slalc I-aNs rrlalirg lo huikling cooslruction. antl hcrclrv arilhr)rizc reUcscntilliles oflllis ( ilv <br />\ ilh all City nil(i (i)unty <br />and (irunly lo ento upon th€ <br />f,l l ltv <br />l'(rnl <br />AA&tlsr <br />QL+<y' <br />firr^r", <br />SITE-WORK DATE ID/SIG.COMMENTS <br />,Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subfloor/VenUl nsu lation <br />Roof Sheathinq <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 />i-rK*vlFINAL -) <br />Certificate of Occupancy Y V <br />Notes, Remarks, Etc <br />> <br />BU!LDING. INSPEGTOR RECORD <br />8 h <br />1 <br />r) <br />L