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BU!LDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNRR BTIILDER I)EI,(-ARA'I'ION <br />IherchyaffirmundcrpenallyofperjurylhatIarnexemplfromthcContraclors l-rccnseln\rforlhefirllowingrcason(Sec.7o.ll.5 <br />Busincss and Profession Code)r nny Cily or ('ounly which reqrircs a pennit to conslnlcl. Elter. improve. demolish or repair any <br />stnrclurc.priorloils issuance.alsorcquireslhcapplicanllorsuchpennittofileasigncdstatement thalheorsheisliccnsed pursuanl <br />lo lhc nrovisions oflhc ('onlraclor's l-icensed [:w (('hapler 9. Commencing wilh Scction 7000 ofDivision.l ofthe Business ard <br />Prcfcssions('odc)orlhalh€orshciseremplthcrcfrornandthebasisfortheallegedcrcmplion AnyviolalionofSecli(in70.11 5bvan). <br />applicantforapennitsilhieclslhe applicanttoacirilpenaltyofnotrnorclhanfivchlndreddollars(9500). <br />. l. as orvner ol the property. or my enlployccs wilh wagcs as thcir sole cornpensation. s'ill do thc work 6nd lhe structure is irot <br />in(mded oroffcredforsale(S(.TM4.BusinessandProfcssionsCode:-IheContractor'sl.icensel{wdoesnotapplyloanoNnerof <br />lhc preperly who huilds or impro\'6 lhtrsn. and \r'ho do6 such worl himselfor hcrselfor through his or her os'n employees. <br />providcdlhalsuch impro!'otntsarcnolinlendcdorofferedforsale.lf.horvevq.thetNildingorimpmvementissoldtrilhinone!€ar <br />()[coinpletion. lhe ( xlner Builder $ ill hale the burdef, of prc\ing lhat hc or she did not huild or improve rhc frcIqly for lhc pu{nse of <br />sale). <br />l. as os ner oIlhe propffr-. am crchrsively conlracling wilh liceilsed contraclor! to constnrct lhe projed ( Scc. 7(H.1. I]usiness <br />and Professhn(-odc: lhcContraclor'sl-iccnscl.as,doesnolapplytoanoNnerofproperly!vhobuiklsorirnpro\csthercon. <br />and \vho conlracls for such proiccls \vilh a ('onlraclo(s) license(l pulslranl to the ( ontractor's l.ic€nse l.aw). <br />I flrn exemft !n(ler Seclion Il. & P.('. tor lhis reason. <br />I)slc ()rner <br />WORKERS' COMPENSATION <br />I hercby affirm under penalty of perirxa one of ,h. li,lln.uingDf,#ffiq <br />- I have afld N ill maintain a Ce(ificalc ofConsenl lo Sclf-lnsure for workers conrpensation. as prolidcd for hy Scction lT00 oflhe <br />I nhor ('odc. for the pofirnnance of lhc $ork for \r hich lhe pemit is isstrcd <br />ftave and ruill rn6inlain workers cornpcnsation insurance. as rcquired by Sccti()n 11700 of lhe Labor ('od€. for the performanc€ of <br />lhe work for shich lhis perrnit is issred. My workers compcnsalion inlurance catrier and policy number ate: <br />,.,,,i", A/YL€ f ILAN AO"\t^lAt,ZU i I <br />poricvNilmber: O||G\T( - O ( rrn;rcs yl, lP <br />I certify that in lhc pcrformance ofthe rvork for which this pcrmit is issued. I shall nol employ any person in any manncr <br />so as to hccorire suhiecl lo lhe workos' compensation laws of Califomia. and agrcc lhll if I slrould b€comc subjcct to thc <br />works' compcnsslion proYisions ofScction -1700 oflhe tnbor ('ode. I shall. fodhNilh comply $ilh Ihosc pro|isions. <br />WARNING: [ailurc lo sctrte worken' compensalion coveragc is unla$ ful. and shall subjecl an onployff to oiminal Fnaltis and <br />civil lines up k) one hundred lhousand dollats ($100.000). in addition lo the cosl ofcompensalion. damages as proridcd for thc <br />Section :1076 oflhe L.hor Code. intcrest and sttorney s fees. <br />Appllonl: <br />LI('ENSED CONTRACTOR <br />DECLARA'TION <br />I hereby aflirm under penally of periury lhat I an licensed under provision ofChapter g (cotrxilencing rvith Seclion 7000) of l)i!ision ll <br />of lhe Business and Professions (bde. and mv license is in full forcc nnd efTect <br />t.icensectass C-- 15 <br />,^,, AHL(L6 <br />l.icense Nunrlrcr:q 997'L t <br />(L-^*L-' <br />I herchy affir,n under pcnally of periury lhal lh(e is a <br />issucd (Sec. .1097. ('ir. ( .). <br />l,ender's Nanre <br />ion lending agency for thc perfotmancc ofthe Nork for which Ihis 6nnit is <br />l-ender's Address: <br />APPLICANT DECI,ARATION <br />I lEeby alli[n under penalty ofperiury one ofthe follo!ving declarati(!ns] <br />I)enrolilion Permits-Asheslos Notificntion lrederal RcSulalions ( Iillc 40. Pali6) <br />Rcqlrired I ellcr ofNolificalion <br />I cedify lhat thc fcdcral regulat ions r.garding sshcstos remo\ al arc not applicahlc to this project. <br />I ccrlily lh^l I harc rcad this applicfllir)n and slalc lhal lhe alx)ve inlirilnali(il is cone.t. I agree lo coillply wilh all Cit.r' and (irunty <br />ivcs ofthis ('ily and ('ounly to enter upon lhc <br />/t <br />o^t" /c (z't lttr <br />'ii'il*l,l*i'W"' <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subfloor/VenUl nsulation <br />Roof Sheathinq <br />Shear Wall <br />Framing <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 />Engineer Final Report <br />Flood Zone Certif <br />t t <br />FINAL 4/M/U --trL 3/r,^ LAd <br />Certificate of Occupancy (vr \_7 <br />Notes, Remarks, Etc <br />Rev ()B ()i,'()1{ <br />Dricl