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BUILDING. INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG.COMMENTS <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenVl nsu latio n I <br />Roof Sheathinq 7,1 btra-o 7 <br />Shear Wall I <br />Framing <br />lnsulatio nlEnerqy <br />Drvwall <br />Ext./lnt. Lath <br />Brown Coat <br />[\Iasonry <br />Poo! Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />.t /\. <br />F!NAL 1?'1 |'lr0 UWtrfI <br />Certificate of Occupancv <br />Notes, Remarks, Etc. <br />OWNER BUILDER DELC/IRATION <br />I hcrcby affrm undcr lEnalty of Frjury thst I m cxctr{rt ftom the Contraclos' Licms kw for thc following Bsn (56.7031.5 <br />Busincss urd Prcfcssion Codc): Any City or County which rcquircs a Jrmit to constmt. altcr, imptovc, &rclish or rcJnir uy <br />structurc. ltrio] to its issumc. alrc rcquircs thc applicant for such pcmit to filc a signcd statcmnt lhal hc or slE is liccnsd pursuot <br />Io thc provisions of tlrc Contractor's Licensd bw (Chaptcr 9. Comrcing with S€tion 7fi)0 of Division 3 of thc Busircss ud <br />Prcfcssions Code) or that hc or shc is cxctr{,t tlEcfrcm and thc bqsis for thc allcgcd cxcmplion. Any violation of Sstion 7031.5 by my <br />.Jplicant far a Frmit $bjqls thc applicant to s civil pcmlty of not mrc thu fivc hundrcd dollus ($50O). <br />I'J <br />Ab. o, owrcr of thc 1mpny. or my cmplo)rccs with wagcs as tlrcil slc $mtEnstion. will do thc wtrk ard tlrc smEtrc is mt <br />intcndcd or ofiercd for sle (Ss.7O44. Busircss md Pmfcssions Codc: Thc Contraclor's Liccns Law docs mt alply to an owrcr of <br />thcpmlEny whohuildsorirpmrcstlEmtrsldwhod6srchw*himsclforhcrclforthmughhisorhcrownemployccs. <br />providcd that such imprcrcmnts m mt inlcrdcd or offcrcd for sb. lf, howrcr, thc buiHing or iE{,rcrcrcnt ir mH within one )qr <br />of cotr{,htiotr rhc Owrcr Buil+r uill haw thc htrdcn of pmvin8 llul he or shc di, rct buiH or ir{,mrc thc prcFrty fd tlE purpo* of <br />slc). <br />_1. as owner of thc property. am exclusivcly contracting with liccnscd conlractors lo construct the projc'ct (Scc. 7044, Busincss <br />and hmfirssion Codc: The Contractor's Licensc Law docs not apply to an owner of propcrty who builds or improves thcrcon. <br />and who contracts fbr such projccts with a Contractor(s) liccnscd Contractor's Liccnsc Law). <br />,_l am cxcrnpt urtclcr <br />l, <br />I lrercby atfirrn undcr penalty of perjury one of thc following <br />.--lhavcandwill nraintainaCcrtificatcofConscnttoSclf-lnsurcforworkers'cornpcnsation,as gnovidcdforbySection3T00ofthe <br />I-rbor Codc. for the pcrfornurnce of thc work for which thc permit is issucd. <br />_l havc and will nraintain workcrs' corrrpcnsali<ln insurancc. as rcquircd by Section 370O of the labor Codc, for thc performarce of <br />thc work for which this pcrnrit is issucd. My workers' compcnsation insurance carricr and plicy numbcr are: <br />workers' compcnsation provisions of Scction 37fi) of thc L:bor Codc, I shall. forthwith cnrnply with thosc provisions. <br />WARNIN(}: Failurc to sccurc workcrs' cornpcnsation covcragc is unlawlul.sutrjcct an crnployer lo criminal pcnaltics and <br />civil fincs up lo onc hundrcd thousand dollars cost of comlrcnsation. damagcs as providcd for the <br />Scction 3076 of thc l-.abor Codc. interest and attorrrcy's fccs. <br />I lrcreby al'llrrn undcr pcnalty ol'pcrjury that I anr liccnscd undcr 9 (comnrncing with Scction 7000) of Division 3 <br />of thc Busincss and Prol'essions Codc. ard rny liccnsc is in full frrrcc and cffect. <br />Liccnse Class: Liccnsc Numbcr: <br />l)irle: <br />CoNSTRUCTION LM{DING AGENCY <br />I hercby rf,im undcr JEnalty of lErjury thol thm is a onstruction bnding agercy for thc pcrfotlrc of thc sork for w,lich this Imit is <br />issued (Scc. 3097, Civ. C.). <br />bndcr's Nam: <br />[.cndcr's Address: <br />A PPLICA NT DF'CLARATION <br />I hocby aflinn undcr pcnalty of pcrjury one o[ thc following dcclarations: <br />Dcmolition Pcrmits-Asbestos Notification Fcdcral Regulations (Title 40, Part6) <br />-Rcquired <br />lrtter of Notification <br />infornration is corrcct. I agrcc to cornply with all City and County <br />and hcrcby authorize rcprcscnlativcs of this City and County to cnter uSnn the <br />atrovc mcntioncd propcrty for inspcction <br />Applicant or Agent I <br />Pemritee nunre e <br />I <br />ev. 08-07 -2015 <br />, <br />t(, <br />cerlify that in the pcrfornurrce of thc work firr which this pcrmit is issucd. I shall not crnploy any pcrson in any manncr <br />if I should bccorrc subjcct to thc <br />rl,r( 1)n <br />Contractor:_ <br />-l <br />ccrtify that thc fcderalrcgulations rcgarding asbcstos rcnnvalare nol applicablc to this projcrct. <br />ccrlily that I havc rcad this <br />and Statc l-aws rclating to