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COMMENTSSITE.WORK DATE ID/SIG. <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenVI ns u lation z/tlr',EW tbz <br />Roof Sheathinq zltoltq >Ail/o1 <br />As-7td tlt'Shear Wall tlql t t <br />Framinq dz, lA B,r:r€ lo) <br />lnsu lation/Enerqy <br />Drywall $/utlrq offi/o) <br />Ext./lnt. Lath 8/e-t ltq BtA to.a, <br />Brown Coat Qln lr q oZ*{laa <br />[/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />nfsftUh,fuo* Sar <rt ilnl,s z/tln <br />'1oo^.*?ru 4t*glzolp.H les:2 <br />der't)FINAL i"l tQ lttt \Z-/firyut,ti <br />Certificate of Occupancy ll ul <br />Notes, Remarks, Etc. <br />()lvNI.ll{ <br />I hcrohy allirm undcr pcnalty of pcrjury that I am cxcmpt l(rm thc Cinrlrack)s' l-iccnsc law tbr thc lolk)wing rcr$n (Scc.}!hi <br />Busincss antl Prrrfcssiun C'rxlc): Any City or County which rcquircs a lmil kr cooslntcl. ahel improvc. rlcnxrlish or rcpaii any <br />struchrc, prirr k) ils issuancc, aly) rcquircs thc applicant t)r such Jrcr[ril k) l'ilc a signcd stalclEnl that hc or shc Ls'liccn*d ptrsuant <br />b thc provisions of tlrc Contrack)r's Liccnscd llw (Chaptcr 9, Comnrcncing wilh Scclion 7(X[ of Division -l of thc Busircss fnd <br />Pn)lcssionsCode)orthathcorshciscxcmptthcrcliomandthcbasisli)rthcallcScdcrcmptiotr. AnyviohlionofSetionTO-ll.5l'yany <br />applicrntli)ralErmilsuhjcctsthc applicantk)acivilpcntlty(rffrrlntlrcthanfiv('hundrc.ldollds(S5m). <br />_1. * owncr of the pr)lEny, or my cmpl()yccs with wagcs as tlrcir solc comFnsalirrr, willdo lhc work ukl lhc slrulurc is ft)l <br />intcnlcd or()lltrcdti)rsillc(Se.?(M4.BusircssandPr)lcssi()nsColc:ThcConlrack)r'sLiccnscliwdocsnotaPplyloanowncr(,1' <br />thcpn)IErty wh()builds([in{K)rcstlEG}n,axlwho&rcssilchM)rkhinrsclforhcrsll(trlhn)ughhisorhcrowncnlployecs. <br />pn)vidcd thtl such imp(rrcnrcnts rc [{ ir{cndcd or ollcrcd li}r slc. lll lr)wcvcr, lhc builling or irporcnrcnt is soll wilhin onc ycu <br />ol complction, thc Owncr Buildcr will harc thc hurdcn ol pnrvinS that hc or she did &)t huill rtr impruvc lhc pntlEfty ti)r tlrc puqr)$of <br />sab), <br />_1, as owncr ofthc p(rpctly. am exclusivcly coilracting wilh liccnscd contruclors k) conshuct thc projcct (Scc. 7044, Brsincss <br />.nd PRltilssi)nCodc:ThcG[tracior'sLiccnscl-awdocsftrlrpplyk)!nowncrofprolrcnywhobuildsorimprovcslhcrcon. <br />and who conlracts li)r such pmjccts with a Grnlracl(r(s) liccnsd pursuanl ft) lhc Conlrack)r's l-icensc lnw). <br />_l a:n excmpt undcr B. & P.C.tlris <br />o^tu,t 6- l?- I 4 <br />DECLARATION <br />I hcrcby afl'irnr undcr Jrcnalty of ;rcrjury one ol'lhe lirllowing rlcclaral ions: <br />_l havc antl will maintain a Ccrtilicalc of Conscnt to Sctf-lrrsure lbr wrlrkers'crtnrpcnsalion, as providcd tirr by Scctirtn 37fi) rll'lhc <br />Lahlr Ctxlc. lilr the pcrtilrnrancc of thc work lbr which thc pcrmit is issucrl. <br />_l have and will maintain workcrs' compcnsatiotr insurancc. as rcquircd by Scction J700 ot'thc Labor Crldc, lbr thc pcrltlrmancc of <br />thc wrlrk lilr which this Jrcrnrit is issucrl. My workcrs' comlrcnsation insurancc carrtcr and grlicy numhcr arc: <br />Policy Numhcr: ExPires: <br />_l ccrtilythat in thc pcrklrnrance ol'thc work lirr which thrs;rcrnrit is issuctl. I shall not cntpkry any pcrs()n in any nlrlnllcr <br />so:tslohcconrcsulrjecttollrcworkcrs'comlrcnsatiorrlirwsol'Calilirrnia.attdagrcclhittit'lshoultlhcconrcsuhjcctttlllr' <br />wgrkcrs' conr;rcnsation provisions ol'scction l7(X) ol'the Lahrr Crxlc, I shall, lirrrhwith conrply witlt thrlsc llrovisions. <br />IVARNIN(i: ljailurc to sccurc worke.rs' conrpcnsation covcragc- is unlawlitl. antl shall strhjccl an cmpkryt-r to crintinal pcnaltics and <br />civil l'incs up lo onc hundrcd thousand dollars in addition to lhc cost ttf contJrcnsatitln. damagcs as provirlcd tirr lhc <br />Sccliott J076 ol'tltc Latxrr Crilc. inlcrcst and <br />tatez' 6- I V- / q <br />t <br />I Scrchy atf irnr undcr pcnaltyol'pcrjury that I arn liccnsctl untler prcvision of Chaplcr t) (ctlmnrcncing with Section 7fr) r'l'f)ivision J <br />ol' thc Busincss and Prcl'cssions Cotlc, and nry liccnse is in tirll tirrcc and etl'ect. <br />a <br />Liccnsc Class: l-iccnsc Numhcr: <br />CONSTRUCTION LENDING AGENCY <br />I herchy allirm undcr Fnalty of JLrjury that tlrcrc is a corstnrct i)n lcnding agcncy ltrr thc Jrcrlbrmancc (,f lhc work li)r which this Frmil tr <br />issrrcd (Scc. .1097, Civ. C.). <br />lrnrler's Namc: <br />lrnder's Addrcss: <br />APPLICANT DECLARATION <br />I lrrcby atl-rnn undcr penalty ol'perjury onc of thc lirlklwing tleclarations: <br />Dcnxrlition Pcrrnits-Ashcstos Notil'ication Fcdcral Rcgulations (Titlc 40. Pan6) <br />-Rcquircd <br />[-cttcr ot' Ntililicatittn <br />_l certilythal the l'cdcralrcgulalions regruding ashcslosrcntoval:trc tt()l applicahlc'lo lhis prrjcct. <br />_l ccrlify that t havc rcarl this application arxl statc lhtt lhe atxrvc intirntratirln is corrcct. I .lgrcc l() conrply <br />ivcs ol'this City <br />with allCity antl Counly <br />and County lo cnlcr ttprtn thcordinrnccs and Statc Laws rclaling to huilding <br />irhovc nrcnliottcd prrrpcrly lirr <br />Applicant or Agcnl <br />Penrrilcc nanrc (print <br />axl hcrcby authrtrzc rcprcscntat <br />*,- (- /V- /? <br />INSPECTOR RECORD aE .'. <br />/ <br />( 'rr ri.- r'