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BU!LDING. INSPECTOR RECORD <br />tltil,( ARA'l l()N <br />I hcrcby ulllrnl undcr pc|tlty of Nrjury that I rnr cxctrrpt froN lhc Conlrilcl(trs l-iccnsc lnw li)r thc li)lk)wi0g reoson <br />Business nnd Profcssioo Codc): Any City or County which rcquircs r lrertrlil lo conslnrcl. alter. improvc. dcnmlish or <br />structurc. pri()r to its issuancc. also rcquires thc applicxnt for such Frrnlit lo filc a si8ncd stalcnrcnl lhal hc or shc is liccn\cd <br />k) thc provi\ions of lhc (i)nlrack)r's l,iccnscd Law (Chaptcr 9. C(nrnrcnciilg wilh Scction 7(XX) of Division I of the Busincss <br />ProfessionsCodc)orthathcorshciscxcmpllhcrcliomandthcha\i(li)rthcallcgcdcxcmption. Anyviolali(ilofScction70-1l.5by <br />rpflictnlli)rtpcnlilsuhjectslhc lpplicantloacivilpcnrltyofnolrnorclhailfivchundreddollars(S5U)). <br />_1. rs owncr of thc propcny. or nly cnrpbyccs wilh wtgcs as lhcir solc conlpcnsalioil. will do Iltr work an(l lhc stMlurc i\ n(il <br />iilcndc(l oroll'crcdforsillc(Src.7044.llusinessandl'rol'cssionsCrxlc:'lhcCotlracbr'sLiccnscl,rwdocsnolapplytoanowncrof <br />lhc proprty Bho huilds or improrcs lhcrqnl. and who d()cs such wrrk hinrsclf or hcrscll or lhrough his or hcr own cnrphryccs, <br />providcdthitsuch improvcnEntsarcn(iliilcndcdorollcrcdforsrb.ll.howcvcr.lhchuilditlgoriNprovctmntiss(,ldwilhinoncycxr <br />ofconlplcti(nt. rhL Owncr Buildcr will hn$c thr hurdcn ol proving lhill lE or shc dkl nol build or iilpro\e thc prcFny li)r thc pnrF){ of <br />srlc). <br />_1. rs owncr oflhc pr)pciy. am cxclusivcly co[lrrcling with liccnscd contrachrs k) conshlcl thc projccl (Scc. 70i14. Bil\iilc\\ <br />anl PnrlissirrCodc: lhcContractor's[,iccnseLawdocsnolapplytoanoq'nctofpropertywhobuildsotitrlprovcslhcrcon. <br />and who contracls li)r such projccts wilh a Conlrrchr(s) liccnscd pursuant kr thc Conlraclor's l,icense lnw). <br />_l anl cxcnlpl undcr Sccl B. & l'.('. lirr this rcil\{,n. <br />I)alel ()sner <br />IvoRKERS' ( ()llPliNsAl loN <br />t)trcl,ARA l l0N <br />I hcrcby aftlrnrunder Irctrnlly ofperjury(nrc ofthc lollowing dcclarnthns: <br />_l havc axl will nuiilaih a Cenifrcatc of Consenl t) Sclf-lnsurc li)r wotkers' conrFnsation. as providcd for by Setion 37{X) of lhe <br />tabor Codc. for the pcrlitrnuncc ofthc work for which thc permil is issucd. <br />_l havc tnd will.maiilttin workcrs' coillncnsalion insurailcc. us rcquircd by Scction 3700 oflhc Labor Codc, for the Pcrlbrillancc of <br />lhc sork l()r thi\ pcrmil is issucd. My workcrs (otrrpcnsfllion iil\urnncc cnrricr and [x)licy numhcr arc:,i- <br />t <br />Policy <br />_l ccnily thnt in thc lErlirrnunce of thc work ftrr which this pcrnrit is issucd. I shrll nol cnrploy any pcrson in dny nranncr <br />soasloheconlcsuhjccttothcworkcrs'conrpcnsiltionlilwsofCalifornia.andagrccthaliflsh(tuldhccotrcsubjccltolhc <br />workcrs'coilUcnsationpnrviskrnsofScclir)n370()oltheLatx)rCodc.lshall.li)flhwilhconlplywilhthosprovisions. <br />WARNIN(;: Frilurc k) sccurc sorkcrs'cornpcDsalion .ovcragc is unlawful. nnd shall suhjccl 0D cnrphycr lo lTiDiDal pcoilllics and <br />civil linesuptoonchunrltcdthousanrldollarstSllx).(xU).inrr$itiontolhgcrllo[corirltn\rli(tn.dunrrrgcsrsprorirlctlfrrtthc <br />Sccrioil .l{)7r;ol fc l.ahrTcorlc. inlrrc\l rnd atktrnc(\ l'E's. l2l ,// I <br />r)are: 3 ll o1i6 ,rppri.#i.\ ,44-/ (4r/--?- t . @*.*r"ffis"*r* <br />I hcrchy xllirnr undcr pcnillly of pcrjilry thnt I atrr liccoscd undcr prorision ol Chrplor I (connncncing with Scction 7(Xm) ol Division .'l <br />ol thc llusilcss and I'rolcssions Codc. and nry liccnsc is in Itll li)rcc nn(Lffccl. <br />737t2cl.iccn\c (-lx\\ <br />l)ale:3 a3 <br />CONSTRUCTI()N LENDING AGENCY <br />I hcrcby allirm undcr frnalry of pcrjury that lhcrc is a conslruclion lcnding agcncy {i)r lhc perlbrnuncc of Ihc work for which lhis FErmil is <br />issucd (Scc. -1097. Civ. C.). <br />l-cnder's Nrnlc: <br />[,cildcr's Addrcss: <br />APPLICANT NECLARATION <br />I herchy dllirnl undcr ltlally of pcrjury onc of lhc folk)wing declartlions: <br />Dcmolition Pcrmits-A\hcslos NolillcalioI Fcdcral RCEUlalions (Tillc.10. Parl6) <br />-Rcquircd <br />Lettcr of Notification <br />-l <br />ccnify lhal lhc fcdcrul rcgulalions regtrding ast{slos temovtl arc nol aPPlicuhlc to this Jrrojcct. <br />_l ceniiy that I havc rctd this applicali([ ilkl slrte that the alnvc inlbrmfllioil is corcct. I a8rce h comply with all City and County <br />i#,'[i#, <br />DATE ID/SIG.COMMENTSSITE-WORK <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVl nsulation <br />Roof Sheathing <br />Shear Wall <br />Framinq <br />lnsulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />lVasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />FINAL <br />Certiticate of Occupancy <br />Notes, Remarks, Etc. <br />(t"4-