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BUILD!NG. INSPECTOR RECORD
<br />SITE-WORK DATE !D/SIG.COMMENTS olvNuR lrt[l,t)t:R t]EI_cARA't'l()N
<br />I kreby rlfirnr under penulty ofpcrj!ry that I 0n) e\enrpl fronr the (.irtrtractos l-icense Law for the following reasol (Sec.7031.5
<br />llusincss And P()ltssion Codc): Any City or County which requircs n fErinit k) c(rn\lnrcl, lllcr. irnpmvc. dcm)lish or toai!Jny
<br />to lhc nft)visions ol'lhc Conlrack)r's l,iccnscd Iiw (Chaptcr 9, (lnnnrcncing wilh Scction 7(XXl ol l)ivision 3 ol'lhc lJusincss and
<br />ProfessioNC(xletorthatlrcorsheiseremptlheretronraildrhebu\isli'rllElllegedexcilrnrioil. Anyviolari(rofSecti(n70ll.5byany
<br />ilpplicdnl lbr n frrilil subjects thc rpplicrnt lo r ci! il perultv ol nol nnrc lhotr live hundred dollilrs ($5(x)).
<br />_1. as owncr ()l thc prolEfly, or rny crnployccs with wngcs is lhcir solc c()rnpcnsati(rn. will do (hc work rnd rhc structrrc is not
<br />irlendetl or ofltrerl lbr sale (Se.70.1,{. Business rnd Pft)fessions Co.ler l'hc Conlrnclrn's I-iccnsc Lnw does nol npply b an owner of
<br />the ptr)pcdy who builds or inIft)ves therilD. ard wh, d()es such worli hinrselfor herseli(,r lhrongh his or her owtr cmpl)yees.
<br />p,o\idedlhrtsuch irnpfllv.lrnlsecmlintcrrlcdorollircdlor$L. ll.hoscv.'r.thLtilildingorirnprovcrrcntis$bwilhinonc}!tr
<br />ofconplcti(nr tlE Owrcr Buiklcr will have the burden of pn)virU! llil lt or shc rlid ftl build or irprove llrc fnrpny for tlt puryrrr of
<br />s!lc ).
<br />l. as owncr olthc prlpely, an) exclusively c(nlracti,r! wilh licensc(l cotrlrnckn's k) c(nl\lruct the project (Sec. 7(X,1. Burirrers
<br />arrd F\olissirrr(irde:TheContractor'sLicerrel-awtloesrctapplytrrarownerol'propertywhobuildsorinlprovcstllere(trr.
<br />rn(l s,h() cr)nlrncts for such pftriccts rvith a (irntracktr(s) liccnrc(l pur\urnl lo lhc C(,nlrrclor's Liccnsc Lalv).
<br />_I anrexenrln !Rlcr Sect I] & P.C li,r rhi\ rea\oI
<br />I
<br />W( )RKI.IRS' (\)Nll'IINSATION
<br />T,ECI,ARATIoN
<br />I hcr!'hy n,lirm undcr pcnalv ol pcrjury onc ol lhc I(,ll('wing dcclarali(Ds:
<br />l,ahrr Codc, li,r thc r-rformAn(c o[ lhc work li)r which lhc peilnit is issu.(l
<br />_l have and will mainraitr workers c()n)petrsali(tr1 rr\nrxnce, is requircd hy Secli{rl l70O of lhe trhor (i)de, f(tr lhe perfornw)ce of
<br />rlr' work l()r whlch lhis Nrnnl i\ is\ucrl. My workcrs' cotrrJxnrali(in iDsulilncc canicr iwl lx)licy numb.r uc:
<br />(
<br />l,olicy Nunrher: llxpircs: _
<br />_l ccrity rhilr rD tlrc pcrli)rnuncc ()l'rlE work li,r s,hich lhis pcrnlil i\ issuc(I, I shall n({ enrploy any lrcrson in any manncr
<br />sorrlotrcoDEluhjcctlothcu,orkcrs'conrl^*ilsllionlnw\ofCrlrlbrDin.rnilrgrcethatiflsh)uldhaconrsuhjcctlolhL
<br />worlers (onr|ro\rl,oDp(^'i\tnNofSection.lT00ofthet-abor(irlc,lshrll,fonhwithronrplywilhlltosprovisions.
<br />WARNINGT liililrtr'c k) sccurc work!:rs'conrlf,:nsaliol covcriSc is unlilwlil. anrl slHll suhjcct nn cn)l)k)ycr t) criminul lrcnalties xnd
<br />civil llnes uI k) one hundred thousrnd dollrrs ($l(X1.0(X)), itr rddili{iI lo lhe cost ol cornp€nsnlion, drnrrSes As providcd lbr lhe
<br />Scction :1076 r)fthe t-ahor Code. iilerest and rtlorrcy s I;es.
<br />l)rl(
<br />1,I(]ENSED C()NTRA(]ToR
<br />DECI,ARATI0N
<br />I hcrcby al liiln undcr pcnalty ol pcrjury that I arn Iiccnscd undcr provirir)n ol Chaptcr 9 (corn,ncncing with Scclion 70fi)) ol l)ivision 3
<br />(,f lhe Ilusincss ilnd Pruflssi(,ns Co(lc. sd my liccnsc is in full lirrrc un(l cftcct.
<br />l.iccnsc Cl^ss:-Liccnsc Numbcr:
<br />Cotrlrtrcl0r:
<br />C0NSTRTJCTION I,I,]NI)ING AGENCY
<br />issuod (Src. 1097. Civ C.).
<br />l,cildcr's Nrnrc:
<br />I.cntlcr's Adrlrcrr:
<br />APPLICATIT DECLARATION
<br />I ltrcby ilfltrnl undcr pennhy of perjury one of Ihc followirrg (leclarilt ions:
<br />Den)olition Pernrils-Asbestos Notification Fccleral ReSulations ('fitle,l0, Pait6)
<br />_Required I-ctter of Ntlifi cation
<br />_l cenify that rhc llderal rrguhti{nN regarding nrhcsk)s renx)vill rrc Nr applicnble rr) rhis project.
<br />_l cenify lhat I lrave reatl this applicalioh and stnte lhrt lhe above infortrulion is correct. I ngree to comply wiLh all City anrl County
<br />ntx)\'( nEnt()nc(l pfi)lEny ti)r inrpccti()n puqx)scs
<br />,\pplican( or,\getrl l)iltc
<br />Prnniler narnc lnrint):
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsu lation I .9/
<br />Roof Sheathing Y/17 2^{'tz0 DIU,|tyta t4dD
<br />Shear Wall I I
<br />Framinq
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lMasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />FINAL 11 e?w4a2j7
<br />Certificate of Occupancy
<br />NoteS, Remarks, Etc.Ir
<br />Q)r- l, l v
<br />tlev. Lt8-07-2015
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