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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS O\\ \llll llt ll.l)l'.ll l)lal.( \l{'\I lO\ <br />I hoeby affirrn undo poalty of psjury that I an exenlpl from the ('ontraclom- l-icmse l-as' for lhc follosing reon (54.70-11.5 <br />Business and l'rofession Corle): Any City or County rvhich requires a pmnit to construcl. alto. improve. demolish or repair any <br />slmcture. prior lo ils issuance, also reauirs lhe applicml for such Frrnrit lo filc a sisncd stalonent lhal he or she is licorsed pulsuanl <br />to the lrovisions oflhe Contractor's l,icensed [.aw (Chaplcr 9. Connnencing rvith Smtion 7000 of Division 3 ofthe Business iind <br />professions Code) or lhat he or she is erenlpt thqefrorn and the basis for the alltled exernption. Any violBlion ofSection 70-1 1.5 ty any <br />applicanl for a pffilit slbj(ts the applicant to a ci!il penally ofnol tnore lhan five hundred dollils ($500). <br />l. m orvner ofthe proFrcdy. or tny eillployees wilh waScs as their sole corpensalion. \rill do lhe $ork ild the slruclue is nol I <br />irlqrdel or offsed for mle (Se.7Ol4. []usin6 and hofsstrns Code: l he ('onlrackn' s License [-aw do6 not apply lo an oNntr of <br />theprotEny $ht,btrildsorimprovsths6)n.ilrdwhodoL3suchuo*hirnselforherselforthroughhisorhffownenlployeG. <br />providedthatsuch itnprovonentsarcnotinlodedoroffqedforsle.lf.hou'evo.lhehuildingorimprovenrmtissolclrvithirtoneleu <br />ofconrplaion. lhc Orvncr Buildq S ill havc the bordo ofproling thal he or she did not t{tiltl or ilnprove the prefdy for lhe puqns of <br />sle). <br />l. as o$.ner ofthe propc'rly. on erclusively contracling \\ ilh liceilsed conlraclots to conslruct lhe project (S(. 7044. Busirrss <br />and ttofesion(irde: theContractor'sl.icense l.awdo6notapplyloano$nsofpropertywhobuildsorimproYesthocon. <br />and who conlracls for such projects rvith a Corilracto(s) licensed pursuanl to lhe (irntractor's l,icqrse l,arv). <br />I an exempt undcr S(tion <br />Date: <br />. Il & P.( . lirr this rcason. <br />(hr ner <br />\!!l!th!r!!511!ll L\!ll-!-(].\ <br />t)1,( 1.,\ll,\ I IoN <br />I hereby aflirnr under penalty ofpqjury one ofthe follo$'ing declaralions: <br />Ihavemrlrvillmainlaina(enificaleofConstrltoself-lnsurcforworkqs colnpensalion.as [rcvideclforbySectionrT00ofthe <br />Lalxn' Code. for lhe prfomancc of the wo* for rvhich the pmit is issued <br />_lhaveandwillmaint.inworkers coillpensationinsurailce.as rcquiredbyScttion-1700oflheLabor('ode,forlhepofonnuceof <br />the Nork for \\'hich this pennit is issued. My rvorkos compcnsalion insumnce catiet md lblicy number tre: <br />Cariel <br />Polic) Nunrhq:Erpires: <br />I cetlify lhal in lhc performance ofthc \\ork ftn \!'hich lhis pernril is issucd. I shall nol emplo! any pqson in .nv manner <br />so as lo B*otnc subjfr.l lo thc \orktrs' conllmsation la\ s of Califrrrnia. and agree lhal il l should becontc subjccl lo the <br />$.orkcls' cornpensalion prorisions ofS<ticrn l7(X) otthe l.ah)r Codc. I shall. ftnh\\ ilh colnpl)'$ illt thosc provisions. <br />WARNIN(;: lrailure lo secure workeB'compc0snlion covcrage is trnla['[ul. and shall subiecl an snpk)vs lo aitDinal pstaltiG and <br />ciril lincs uP t) oile hrndred lhoilsan(l (lolla$in addilion b the cosl of compeilsation. danages as protided for lhe <br />Secti<r 3076 ofthe l,atnr Codc.fe6 .?/4fr- ft/VS,,llt4 x) <br />Ltu tt (a <br />Lt( t,.Nsl,.l) (1)N I It,\( l()ll <br />t)ucl-ARA iloN <br />rrrrlcr pr or ision ol'( hapld () (comrncnciD! $ ilh Scclioil 7000) oI I)i\ istrn lI hercby a{llrfi undcr lrenalty oI perjury I rrn <br />of the Busin6s and Prof*sions Code, md my license Iirrcc anrl cflcct. <br />Liccilse Classi b <br />l)rlc alzr& <br />I hoebl'aflirnr under ;mall).of pqjury thal <br />issued (Scc. .1097. Civ. C.). <br />l.srdcr's Nantc: <br />lclding agencl for the psfonnance oflhe rvork for \yhich lhis Fnnil is <br />l-ender's Addrcss: <br />,\PPl.t( ,\N.r I)t.( L,\ll,\ l'l()N <br />I horhy allirm under pcnflltl, of perjury one oflhe ft)llowinE declaralions: <br />Denrolition I'crrnits-AslElos Nolificatirrn Fedcral Regulations ('l ille'10. Pan6) <br />Rcquir c(l t-ellca oI Notifi calion <br />thc <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenVl 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 />Enqineer Final Report <br />Flood Zone Certif <br />I <br />///F|NAL 7_/ y /.2{b t v77W.0L{ <br />Certificate of nc' <br />Notes, Remarks, Etc <br />too*8!>- <br />7 tsUtcltts1zt,o <br />E uttD/uqo*"+Jtln <br />u t F ff- fuzorz -lt But Lt>4)E- @.-.Kn-A*r-r ill S 5rL\ *tC