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BUILDING- INSPECTOR RECORD <br />SITE-WORK COMMENTSDATEID/SIG. <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bf loor/VenVl n s u lation <br />Roof Sheathinq <br />Shear Wall <br />Framing <br />lnsu lation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />[t/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />, <br />FINAL la,/;N '.W1ff€Zl|:rd <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />\ <br />I hcrchy aflirnr undcr Fnally of pcrjury lhat I am cxempt fror lhc ConlractoE' Licenrc liw for lhc following rcasn (Scc.70.]1.5 <br />Busincss nnd Pftrfcssion Code): Atry Cily or County which rcquircs a Jrcrmil to conslrucl. .hcr. improlt. dcmlish or ftlxir any <br />struclurc. prior to ils issuancc. also rcquircs thc opplicant for such lrcrmil lo file o sigrcd strtcrrcnl lhal hc or she is liccnsd putsuill <br />to thc provisions of thc Contractor's Liccnrcd law (Chaptcr 9. Conmrcncing with Seclion 7000 of Division 3 of thc Busincss and <br />Codc) or that hc or shc is cxcnrpt thcrcfrom and thc hasis ltrr thc allcgcd cxcnrption. Any violation of Scction T03 l .-5 by arry <br />lirr a pcnnit subjccts thc applicunl lo a civilpcrralty<ll'rtot rttorc thatt fivc hurtdrcd tlollars ($5(X)). <br />()\!'1lcr of thc property. or rny cnrpkryccs with wages as thcir solc cornpensation. willdo lhc u'ork and thc stnrclurc is nol <br />intcndcd or offcrcd for salc (Scc.7044, Busincss and Profcssions Codc: Thc Conlractor's Liccnsc l-aw docs not apply lo an owtrcr of <br />the pn)pcrty who builds or intproves thcrcon. and whcr dcrcs such work himsclf or hcrself or through his or hcr own entployccs. <br />providcd that such improvenrnts arc xtt intcnclcd oroffcrcd for salc. ll. howcrcr. thc building or irnprovenrnl is sold within onc ycar <br />of corrphtion. thc Owner Buildcr will havc thc burden of proving that he or shc did not buikl or inprovc thc propcrty for thc purynsc of <br />salc). <br />_1. as owncr ol'the propcrty, anr cxclusivcly conlracting u,ith liccrrscd corrlractors to conslruct thc projcct (Scc. 7(M4. Busittcss <br />ancl l\rrli:ssion Codc: J'hc Contraclor's Liccnsc Law docs not apply lo iln owncr of propcrty who huilds or ilttprovcs tlrcreott. <br />and who conlracls fbr such projccts with a Contractor(s) liccnscd pursuant to thc Conlraclor's Liccttsc l-aw). <br />_l arn cxcrnt)l untlcr & P.C. lbr '"uh_ <br />I):rtc:l(*,'lzo (_ <br />OECLIR,ITION <br />I hcreby affirrn under penalty of pcrjury onc of thc following declarat ions: <br />-lhavcandwill <br />maintainaCertificatcofConsenttoSelf-lnsurclirrworkers'compcnsalion.as providcdfbrbySection3Tfi)ofthc <br />labor Codc. for the pcrformancc of thc work frrr which the perrnit is issued. <br />_l havc and will maintain workers' contpensation insurancc. as rcquircd hy Section 37ff) of thc l-abor Code. for thc Jrcrfonrrancc ttf <br />thc work for which this prmit is issucd. My workers' comfrcnsation insurancc carrier and plicy nuntbcr arc: <br />Number: Expires: <br />ccrtily that in thc perforrrrancc of thc work lirr which this pcrrrrit is issucd. I shall not crttpkry any pcrson in any nlanncr <br />so as to bc.conrc suhjcct to thc workcrs' conrpcnsation laws of Calilirrnia. and agrcc lhal if I should bccttnrc suhjcct to thc <br />workcrs' compcnsation provisions of Scclion 37fi) of the Lahor Codc. I shall. forthwith cornply with those provisions. <br />WARNING: Failurc to secure workers' comlrcnsation covcraec-llunlawful. and shall subject an enployer to criminal Jrcnalties and <br />civil fincs up to one hundred thousand dollars (Sl9I€6in adiftion to thc cost of comJrcnsation. damagcs as providcd for lhc <br />Scction 3076 of the l-atnr Code. inlercst and attorrrcy's fces. I - <br />oN", t/90 lto ^rr,,*'LICENSED CONTRACTOR <br />l)lrt'l,AlU\'l'lON <br />t hcrcby al'llrnr undcr pcnaltyol'pcr.iury lhat I ant liccnscd urrdcr provision ol'Chaptcr 9 (cotntncttcirrg with Scction 7fir) ot'l)ivisiorr 3 <br />oI thc I]usirrcss and Profcssions Cotlc. and rny liccttsc is in l'ull lirrcc ard cll'ccl. <br />Licensc Class: Liccnsc Nunthcr: <br />Date:('onlraclor: <br />C( )NS'l'ltU("1'l( )N l,liN I)I NG,\(i IiNCY <br />I hcrcby allirnr urdcr JEnally ofperjury thal thcrc is a constructkil lcnding agcncy for lhc lErfornuncc of thc work for which this Jrctnrit is <br />issuecl (Scc. 3097. Civ. C.). <br />I-crrrlcr's Narrrc: <br />lrndcr's Addrcss: <br />APPLICANT DT'CI ARATION <br />I hcreby alllnn undcr penalty of prjury onc of thc following dcclarations: <br />Demolition Pcrmits-Asbcstos Notification Fcderal Rcgulations (l'itlc 40. Part6) <br />-Rcquircd <br />lrttcr of Notification <br />_l ccrlily that thc l'cdcral rcgulalions rcgardirrg asbcstos rcrrxrval arc nol aJlplicablc to this pr<rjcct. <br />ccrlily that I havc rcad this applicalion and statc thal thc ahrvc inlirrtnalittn is correct. I agrcc lo corrrply <br />rcprescntativcs of this City <br />u,ith all City artrl Counly <br />ancl County lo cnlcr ttlxrn l}r'ordinanccs antl Slatc laws rclaling to and hcrchy aulhorizc <br />abovc nrcntioncd proJrcrty for purF)scs.O.Applicant or Agenl /\- <br />Dare:- <br />Pernrilee nanre ( print):_Crr.r\A *,t i'?(- <br />t lslzs