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BUILDING. INSPECTOR RECORD <br />COMMENTSSITE.WORK DATE !D/SIG. <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenU! nsu latio n I L <br />Vlqzuilt#,Roof Sheathinq lot'221?,t ,^ <br />Shear Wal!I <br />Framinq <br />lnsu lation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />JVasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />tl I <br />FINAL IU rLfr1tr/0 vM;hru nft <br />Certificate of Occupancy <br />NoteS, Remarks, Etc. r r t Itr( <br />oM-- I <br />EtruvtilaS atc WVa /W +ut( (W,ttiLUrL&[ <br />rl <br />OWNER BUILDER DELCARATION <br />I hcrchy allirm undcr Fnalty of lErjury that I am cxcmpt t(rm thc GrntrackrN' Liccnre kw for lhc folkrwing rcsvtn (Se-.7031.5 <br />Busincss anl Profcssion Cqlc): Any City or County vhich rcquircs a Jrmit k construct, alls. improvc. rtcmolish r\rcpair any <br />structurc, [trbr to its issuancc, slso rcquircs Ihe applicanl for such lrmit k, filc . sigred stalcmnl that hc ot slE is liccr*llrffag! <br />kr thc pnrvl\ions ()f lhc Contractor's Liccnscd l:w (Chaptcr 9, Comrereing eilh Sclion 70fl) of Division -l of thc Busincss and\ <br />Prulb$siotrs Cqlc) or that lrc or shc is cxempt thsclirm and thc brsis for tlrc allcgcd exemgion. Any vttlation of Scctim 703 1.5 by any <br />applicant for a Frmit suhjccts lhe applicant lo a civil pcnally of not mtrc than fivc hundred dollrs ($5@). <br />_1, as owncr ol'thc propcrty, or my cmployees with wagcs as thcr solc compcnsation, will do thc work and the slruclurc is not <br />intcndcd or oll'crcd tilr salc (Sct.7044, Busfuress and Prolcssions Crxle: Thc Contractor's License Law dtrcs not apply to an owncr of <br />thc pr)pcrty who huiltls rlr improvcs tlrcrcun, and who d<rcs such work hintsclf or hersclf or tlrntuglt his rlr hcr own cmployccs, <br />provitlcd that such inrpnlvcnrcnls arc not intcndcd or <lll'crcd lilr salc. Il, howcvcr, thc buildirtg or improvcnrcnl is sold within ottc ycar <br />ol'comphtion, llrc Owncr Buildcr will havc the burdcn ol'proving that hc or shc did not build or impnlvc thc propcrry lirr lhc purJxrse ol' <br />salc). <br />_1, as owncr of thc proprty. am cxclusively contracting with liccnscd contraclors to construct thc projcct (Sec. 7M4, Busincss <br />and ttot'esskrn Code: Thc Contractor's Licensc Law docs not apply t() an owncr of proJrcrty who builds or imprtlvcs lhcrcon. <br />and who conlracts tilr such projccts with a Contractrlr(s) liccnscd pursuant to thc Contractor's Liccnsc Law). <br />-IarncxcmptunrlcrScctirln-.ts.&P.C.lirrthisrcastln. <br />Date:Owner: <br />wonxg <br />DECLAR/tTlON <br />I trcrcby allirm undcr Jrcnalty o[ Jrcrjury one of the tolkrwing tlcclaralions: <br />_-l havc and will nraintain a Ccrtiticatc of Conscnt to Scll-lnsurc lilr workcrs' contJrcnsation, as providcd lilr hy Scction J700 of thc <br />Latxrr Crxlc, lilr thc pcrlormancc ol'thc work lilr which thc pcrmit is issucd. <br />_l havc and will nraintain workcrs' compcnsation insurancc, as rcquircd by Scct ion 3700 of thc Lahor Ctilc, lirr thc Jrcrlirrmancc of <br />thc work lor which this Jrcrmit is issucd. My workcrs' comlrcnsation irtsuratrcc carricr and plicy numbcr arc: <br />Policy Numbcr: Expircs: <br />_l ccrtity that in thc grcrlilrmancc of the work tilr which this Jrcrmit is issucd, I shall not cmploy any lrcrson in any manncr <br />so as to bccomc subjcct to thc workers' compcnsation laws of Calilirrnia, anrl agrcc that if I strluld bccome subjcct to thc <br />workcrs' comJrcnsation pnlvisions of Scction 37ffi of thc Lahlr Ctxlc, I shall, tbrthwith comply with thosc prtlvisiotts. <br />WARNING: Failurc to sccurc workcrs'comgrcnsation covcragc is unlawful. and shall subjcct an cmploycr to criminal pcnaltics arrd <br />civil lrncs up to onc hundrcd thousanrl tlollars ($100,Uru), in additiott to tlrc cost of com[rcnsatiott, damagcs as providcd tilr thc <br />Scction -3076 ol'thc Lahlr Crxlc, intcrcst and attorncy's l'ccs. <br />LICENSED CONTR/TCTOR <br />DECLARATION <br />I hcrchy atlrm under pcnalty of pcrjury that I am liccnscd undcr proviskrn of Chaptcr 9 (commcncing with Sectkrn 7m0) of Division 3 <br />of thc Busincss and Pml'cssions Code, arxl my licensc is in full titrcc arxl cffcct. <br />Liccnsc Class: Liccnsc Numbcr: <br />l\.,I ^. <br />W <br />I hcrcby aflirm under Fnalry of pcrjury that thcrc is a custructi)n hnding agcncy tbr thc lrcrfbmncc of thc uo(k for which this Imit is <br />issucd (Scc. .1097, Civ. C.). <br />I-cndcr's Namc: <br />[.ender's Addrcss: <br />APPLICANT DECLARATION <br />I trcrchy allinn undcr Jrcnalty of Jrcrjury onc of thc lolkrwing dcclarations: <br />Dcmolition Pcrmits-Asbcstos Notification FerJcral Rcgulations (Titlc 40. Part6) <br />_Rcqu ircd [.c'ttcr of Notilication <br />-l <br />cc(ify lhal thc lbdcral rcgulations rcgarding astrskrs rcmrval arc nol applicrblc lo this prujcct. <br />_l ccnily that I havc rcad this application md statc that lhc alhvc intbrmtidr is corcct. I agre to clrmply with all Ciiy and G)unty <br />ordtruNcs and StnIc llws rclating k, building construction, anl hcrcby autluizc reprcgntativcs of this City and CouDty to cntq ul[n thc <br />abovc mcntioncd pnllrcny lirr irslrcctbn puF)scs. <br />Applicant or Agcnl <br />l)cnttitec nrull('(rrrirrl l: <br />Date:- <br />np.-n7 -2n 1 q <br />,t <br />, <br />(l ) .-ln+(Nrlh lqd r.5II,o <br />IIr <br />nY rl Contractor: