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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS <br />()\\ NI.:ta tlt Il.l)1,;R l)1..1.( .\l{A I I( )N <br />Ih!,rcbylllirmundcrpcnaltyofpcrjurythiltIamcxcilrpllB)mthcConlrrclors l-iecnscLawli)rlhcli)llowingrcason(Scc.7o.ll.5 <br />Busilcss anil Profassion Culc): Any City or County which rcquircs a lrcrmit lo eonstruct. allcr. inrProve. rJemolish or rcpair any <br />slructurc.pri)rloits issuanec.alsorcquircsthcafplicanllirrsuchJrmitk)lilcasigncdslnlctmnl lhxlhcorshcisliccnsd Pursuant <br />h) thc provtsions of thc Conlrrcbr's l-iccnscrl Law (Chaptcr 9. Commcncing wilh Sccti(D 70fl) of Divistrn .l of the B[sincss rnd <br />prrl'cssir)nsCo.lc)orlhrttEorshciscrcnrulhcrcliomandthchasisli)rthcrllcScdcrcmplion. AnyviolalionofScctionT0-ll.5byany <br />applicantl'orapcrnritsubjectsthc afplicantk)acivilpcnlltyolnotnt)rcthanllvchumlrcddollars(S5fi)). <br />_1. as owncr ol thc prolrcfly, or my cnrployccs with wagcs as thcir solc conrlcnsati()n. willdo lhc work aild lhc slrultrc is nol <br />intcmlL'rl oroUtrcdlirsalc(Scc.T044,BusincssdndProlcssionsCode:'lhcContraclor'sLiccnseLlwdocsnotaPPlyloanowncrof <br />lhcpn)fErly whohuildsorimprovcsttrcrdnl.nndwh()d(rcssuchworkhinrsclforhcrsclforthn)ughhisorhcrowncmPl(]yces. <br />providcd lhal such improvenEtrls dc not intctrdcd orottcrcd fbr salc. ll, h()wcvcr, thc huildirS or irnprovcnEnt is $ld wilhin r)nc yctr <br />irl complcrion, tru* Owncr BuiLlcr will have tlrc hurdcn ofprovinS thrl hc or shc did nol huild or improve thc Pn)fEfly lilr llrc Puqxts of <br />silc). <br />_1, as owncr ol'thc l)ropcrly. am crclusivcly contructirul with liccnscd eonlrnrlors k) conslnlct lhc ProJcct (Scc. 7(X4 Busincss <br />anl pnrlissirnCorlc:'lhcConlrilclor'sl-iccnscl,!wdocsnotapplytoanowncrofpropcrlywhobuildsorimprovcslhercon. <br />antl who conlracls lor such pmjccts wilh a Cornrackn(s) liccnsc.l Pursuxill k) lhc Conlrackrr's I.iccnsc l-aw). <br />-l <br />rm c\cmpt under Sccti(}n-. B. & P.C. li)r this rcason' <br />WORKERS' COI\IPENSATION <br />DEC]LARATTON <br />I hcrcby allirm undcr pcnally ol pcr.iury onc of thc li)llowing dcclnralt)ns: <br />_lhavcandwillmaintainaCcrtiiicatcofConscntbsclLlnsurctorw()rkc$ conlpcnsxtion.as pnrvidcrltirrhyScction.lT(X)oflhe <br />lnhor Codc. li)r Ihc pcrli)rmancc oi lhc work lbr which thc permit is isstlcd. <br />A;n'#;li:ml ainwx.kcrs compcnsati()ninsurancc.as requircdhyScclx)n.17(Xl()llhc[.abor(i)Jc.li)rlhcpcrli)rmanccol <br />I-_rnlil is issucd. My workcrs contpcnsnlilrl itl\urancc'canicr imd Jxrlicy trumbcr [c: <br />{ <br />w 0 <br />Policy Nu <br />_l ecrlil-v thtt in thc pcrfi)rntance ol-thc work lor whirh lhis pcnnil is issucd. I shxll nol cnrpkry any prson in any nlanncr <br />so n\ k' h('conrc suhicct to thc workcrs'comFnsali()n laws ()fcrlili)rni{. and u!rcc lhrt if I sl$uld hccolrc suhi.cl to thc <br />workcrs'compcnsalionprovisionsr)lscctionl?U)ofthcl-nhrr(i)dc,lshrll.l(rrthwithconlplywiththoscprovisions <br />wARNING: Failurc to scurc workcrs'conllEnsntion aovcrrgc is utrlnwtill. and shall suhjcct aD cmpl{}yer t) crinlinxl fEnaltics und -(ivll tinc{uplronchunrlrcrllhou\rnddollars($100(x)o) inaddilxtnk)thccr)slofcomPcnsillion rlamatesasProvidcdli}rlhc <br />S.ctirm l{)76 lhc [-rlx)r C(xlc. irilcrcsl rlkl atknncy's li'cs. <br />\ <br />I hcrcby xllirm un.lcr Pcnalty of lrrjnry that I anr liccnscd undcr pn)vision ol (]hlllcr I (commenciltg wilh SectiM 7tX}()) of t)ivisirnl ] <br />ol- thc Rusinc\\ and t'roltssiurs Codc, iltl my liccnsc is in ltll lbrec aoJ clltcl. <br />Nrrrnhet: <br />d,L <br />I-iccns(- <br />(i,nl <br />CONSTRUCTION LENDING AGENCY <br />I hcrcby rllirm under Fnalry of Frjury that thcrc is a construcliln hndinS aScncy for thc pcrlbrmncc ol'thc work for which lhis ltmit Ls <br />issucd (Scc. -1097, Civ, C.). <br />lrndcr's Namc: <br />Lrndcr's Addrcss: <br />AEEIIEANL PESLABAI.I9N <br />I lrcrcby allimr undcr pcnalty of pcrjury onc oi thc li)llowing dcclrratioll{: <br />Dcn()lilion Pcrnrits-Ashcsbs Notilicatiol licJcral Rcgulatiurs ( l illc 40. Pfi6) <br />-Rcquircd <br />lxltcr ol Notilicali(rr <br />_l ccrtil,v thrt thc lcdcralrcgillali(nrs rc8trdiD! nstrcsk)s rcnx)valarc nol appliclhlc k) lhis pr)jcct <br />(cillly lhnl I hrvc t(x(i llll\ nPI)li(:lltrrD rnd statc thnl lhc ilhrvc inlinrnnli(nt is cotrccl. I rSrcc kr conlPly wilh dll Cily anil Counly <br />onlmanccs and Slate hws relaling to huildinS ,rxl hcreby ruthorizc rcfrrcscntalivcs ol lhis Cily and Counly to cnlcr ufxln tlrc <br />rb()vc mc0tirrlcd p()pcfly ti)r tlslrcclxttr <br />Applica[t or Agqrl <br />Pennilce trntrre <br />Lo <br />Set Backs <br />FormsiSteeli Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenUl nsu lation <br />Roof Sheathing <br />Shear Wall <br />Framinq <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 />Flood Zone Cefiif <br />/4' <br />FINAL 7/;6/7 4 i6t)v <br />Notes, Remarks, Etc.