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BU!LDING. INSPECTOR RECORD <br />SITE.WORK DATE !D/SIG.COMMENTS <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/Vent/l nsu lation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />[/lasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Ceftif <br />FINAL <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />OWNER BUILDER DELCARATION <br />I hcrcby alllrm uil(lcr pcoalty of pcrjury lhrt I um cxcilrpl liom lhc Conlrilck)r\' Liccnsc [jw lor lhc lbllowing rcason (Scc.70Jl.5 <br />Busincss and Proltssion C(xlc)i Any City or C(,unty which rcquircs a Jrcrnrit k) conslruct. altcr. imli()vc. dcnrolish or rcpair rny <br />structurc.pri()rk)its is\urncc.alsorcquircsthcilfllicantlorsuchfrrnlitk)lilcrsigncdstatemnt lhalhcorshcislicenscd nursuant <br />lo thc provisims o, llt Contrack)r's Liccnscd hw (Chaplcr 9. Conurcncing with Scction 70()O of l)ivi\ion J of lhc Busincss rnd <br />P()fcssionsCodc)orlhilllEorshciscxcillflthcrclroilrundthcbasisforlhcallcgcdcxcmplion. Anyvi(]lali(mofScctionT0ll.5hyuny <br />npplicantti)rapcnDitsuhjcctrthc applicanttracivilpcnaltyofnolnmrclhnnllvchundrcddollars($5(X)). <br />l. as owncr o[ I hc proFfl y. or my empbyccs with wrgcs as their solc con]pctrsrl ion. will do lhc work aftl lhc slNlurc is nol <br />iilcndcal orofltrcdfor$lc(Str.7(E4.Busirtcssanrll'roltssionsCodc:ThcConlraclor'sLiccnsc[-awdoc\nolapllytoailowncrof <br />thcpmlEny whohuildsorinlprovcslheB)n.aRlwhod(Essuchwo*hirnsclforhcrsclforthroughhisorhcrownemployces. <br />providcd thal such improvcnrnts N ret inlcndql or oflirc{ for sle. li k)wcvcr. lhc buikling or irrrprovcn*nl is $ld within onc }cxr <br />ol'conuhtion. thr Owncr Buiklcr will havc lhc hurdcn of provi[g that hc or shc did Dol huild or improvc lhc pff)IEny for lhe purfnr ol' <br />srh)- <br />_1. ts owncr ol-lhc l)r()pcily. nm exclusivcly conlrrclir)A wilh liccnsc(l conlrrclors lo conslrucl lhc projccl (Scc. 7(N4. Busincs\ <br />ancl lkrlessitrrC--(xlc:'lhc(i)nlrrctor's[-iccnsc[,rwdoesnolapplytornowncrofproperlywhohuildsorinrprovcslhcrco0. <br />antl who conlrrcls li)r such projccts wilh a Corilrilck)(s) Iiccnscd pursuilnl k) lhc Contrilcbr's Liccosc [-xw). <br />IanrexclnntundcrScclion-.B.&P'C'forlhisrclson <br />Dstf:()rr trcr: <br />W()RKIiRS' CO}I PI|NSA'I'IoN <br />pECLARA',il()N <br />I hcrcby 0ffirnr nndcr pcilahy ol pcrjury onc ol lhc li)lkrwing (lcclarnlion\: <br />_l hrvcandwill nuintsiilaCcnificalcofConscntloScl[lnsurel'orworkcrs'conrlcnsclion.as provi(lc(l lbrbySeclion3T(x)oflhc <br />Latxrr Codc. lor thc pcrforiluncc oflhc work for which thc pcrrnit is issucd. <br />_l havc and will rnoinruin workcrs' compcnsation insurancc. as rcquircd by Scction 37fi) ofthc t{hor Codc. for the pcrfornuncc of <br />thc work for which lhis pcrrlit is issucd. My workcrs compcnsation insurancc canicr iuxl Jmlicy numbcr uc: <br />Policv Nunrbcr: Exoircs: <br />_l cedify thtrl iD lhc pcrlirrnuncc of the work lbr which lhis pcrmil is issucd. I shull not cDrploy any pcrs(,n in any manncr <br />s() as to hecorc suhjccl k) lhc workus' coilpcnsalion laws of California. and agrcc ihut if I should bccotrrc \uhjcct to thc <br />workcrs'conrfensalionprovisk)nsofScctionJ?(X)olthcl,atnrCodc.lshdll.li,nhwilhconrplywithlhosprovisions. <br />WARNING: Failurc k) {'curc workcrs'conrJrnsltiol covcragc is unlnsful. and shall subjccl an ctrpk)ycr to dirninal fEnaltics and <br />civil llnes up t(t dollars ($l(X).(XX)). <br />and ntk)rncy s lccs. <br />in add cost of lirr lhc <br />Scction 3076 ol l.atxrr inlcreslr Applictrtrt: <br />I hcrcby allirnr undcr pcnillty of pcrjury that I anr <br />ol the Busincss nil Prolcssions Clodc. rnd illy I <br />provision ol Chnplcr 9 (conlmncing wilh Scction 7000) of Division 3 <br />lull forcc and clltct <br />[.iccnsc <br />I hcrchy aflirnr undcr yrcn{lly of pcrjury thxl lhcrc is n lcndtr8 aScncy li)r the pcrfornrancc ol lhc work lirr which this prnrit is <br />issucd (Scc. 1097. Civ. C. ). <br />Lender's Nanlc: <br />APPLICANT DECLA RA'I'IoN <br />I hcrcby aliirm undcr pcnahy of pcrjury one of thc lblhwing declnrations: <br />Demolition Pcrnrits-Asbcsbs Notitication Fcdcral Rcgululions (Tillc 4{). Pan6) <br />_Rcquircd lrltcr ol Nolification <br />-l <br />ccilify lhilt thc ltdcral rcgulations rcgudinS ashcsk)s rcnDval arc nol applicrblc to this proFcl <br />_l ccrtily lhal I halc rcr(l lhis applical ion u(l \trtc thr[ lhc uh^'c inlirrniltion i\ crnrcct. I agrN k) cotrrply with rll City aDd County <br />ordinrnccs ilnd Slatc [-aws rclating lo <br />xhovc mcnli()n(l prol)clly Iitr <br />Applicont or Agcnt Sigr&lu <br />Itcrnrilee nanre {prinl):( <br />nncl ol <br />J)-J,.?ri {r.A <br />[lndcr's Addrcss: <br />I)slr: