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BU!LDING- !NSPECTOR RECORD <br />SITE.WORK DATE !D/SIG.COMMENTS OWNER BTIILDER I)EI,CARA'IION <br />I hcrcby allirrn undcr pcnrlly of pcrjury that I am cxcmpl liom thc Contractors Liccnsc ljw lbr thc lblk)witg rcason (Scc.70.ll.5 <br />Busincss and Prolcssiol C(xle): Any Cily or C()unly which rcquircs a Jrrnril lo conslrucl. illler. ifiprovc. dcnrolish or rcprir any <br />slruclurc,prktrloils issunncc.illsorcquircslhcapplicnntlirrsuchpcflniltolilcasigncdsliltenrnt thathcorshcisliccnscd pursutnt <br />k) lhc provisioDs ol thc Contrackrr's Liccnscd Litw (Chaptcr 9. Conrmcncing with Sccti(il 7(XD of Division J of thc Busincss antl <br />Proltssio[sCodc)(,rlhulhcorshciscxcnrptlhcrcftomrndthchasisli)rthcallcgedexcnrplion. AnyvblillionofScctionT{)3l.5byany <br />ilpplicrnlli)rapcrillitsubjcclslhc apllicantt)acivilfcnxltyofnotnmrcthanlivchundrcddollars(S5(X)). <br />-1. <br />as ou'ncr of the profrcny. or my colJ,loyccs wilh *ilgcs as lhcir solc conlrcnsal ion. will (lo thc work and lhc stnrcturc is n([ <br />inlcndcd oroflcredlorrille(S*.?0,l4.BusincssandProfcssionsCodc:ThcCorIractor'sl-iccnscLawdocsnotapplytoonowncrof <br />lhcpr)frcny whobuilds(,rimprovcslhcrq,n.andwhod(Essuchwo*himsclIorhcr\clIorthroughhisorhcrowncmpk,yccs. <br />providcd that such irnfrolcnrnls uc not irilcndcd orofliJrcd li)r $lc. ll. howcvcr. lhc huikJing or inrprovcmnt is sold within onc )r:rr <br />ofcoorplction. lhc Owncr Buildcr will havc lhc burden ofproving lhrt hc or shc di(l not build or intprovc lhc pRlpcrly fi)r thc pu{nrc of <br />sah). <br />-1. <br />as owncr of lhc l)ropeily. anr cxclusivcly conlracti,rg with liccnscd contrack)rs k) constnrct thc projcct (Scc. 7(N.1. Busi[css <br />and PlofeisionCoclc:ThcConlraclor'sLiccnscLawdocsnotapplylornowncro[propcrtywhobuildsorinlprovcsthcreon. <br />and who contmcts for such project$ with a Corilraclor(s) licenscd pursuant t) lhc Conlraclor's Licensc Law). <br />-lamcxcmp|undcrscction-.B,&P.C,lbrlhisIcason'l)iltel O*ner: <br />}VORKERS' CONTPENSATruN <br />DFCLARATION <br />l hcrcby al,irD undcr pcnxllyoIl)crjuryonc ol lhc li'lhwirrg dcclnt.li(,ils: <br />-l <br />hrvc uud will ruintilin r Ccnillcrlc olConsetrl to Sclfllnsurc fbr workcr\' coil)Icnsali(n. as prcvided lbr hy Sccti()n -37(X) ol thc <br />t-nk)r Co(lc. li)r thc pcrforilmilcc ofthc srnk ft)r which rhc lrclnir is i\sucd. <br />-lhavcnndwillmaintainworkcrs'conrpcnsalioninsurancc,as <br />rcquircdbyScction3T{)OofthckhorCodc.forthcpcrtbrtrlanccof <br />lhc work li)r which this pernlil is issucd. My workcrs' conrpcnsatk[ insurtncc cafticr and [x)licy numhcr ilc: <br />Poljcy;rlx111r"r' <br />-l <br />ccnily thal in lhc Jrcrlirrnnncc ol lhc work lbr s'hich thi\ porillil i\ i\\ucd. I shrll 0ot cmpk)y any person in any milnncr <br />so as k) ttcont subjccl k) lhc workcrs'conlpcnsillioD lilws ol'Cxlilbrnir. and agrcc lhul il I should hcc()mc cuhjccl to lhc <br />workcr\' c(tnrpcnsrlion provisions ofScction .17fi) ol lhc LatDr Codc. I shall. li)rthwith conlply wilh thosc provisions. <br />WARNIN(i: hilurc k) {cure workcrs' <br />civil fincs up to oDc hundrcd thousatrd <br />Scction 3076 ol lhc tik)r Codc- intcrcst <br />comFcnsalioD covclagc subiccl ril cnrpl()vcr l() crirninill trcnrllics an(l <br />i(,n l0 c0\! r)l conrlcn\ali()il.as providcd li)r lhc <br />rrxl I <br />,,,",4/ ti / rt, <br />I hcrchy ill'llrnl undcr pcnnlty of unrlcr provirion ofChollcr 9 (conrntcncing with <br />in lull li)rcc tnd ctl'cct. <br />7(XX)) 0f I)ivisi()n -l <br />ol lhc Bu\incss and Prolessi(rns Codc, and my <br />Liccnsc o -iccnsc Numbcr:131 S1./ <br />D^.", q/ l\ll?)\ r u^*t <br />I herchy allirnt untlcr pnahy ofpcrjury lhcrc is a con\truction lcnding ilgcncy li,r thc pcrlirrnrancc of thc urrrk lirr which this Nrmit is <br />issncd (Scc. l0()7. ('iv. ('.). <br />Lcndcr'* A.ldrcss: <br />APPLICANT DECLARATION <br />I hcrcby aflirm undcr pcnalty of pcrjury onc of lhc lbllowing dcclarnttns: <br />Dcmolilion Persrits-Asbcshs Noliflcation Fcdcral Rcgulations ('I itlc 40. PM6) <br />_Rcquired [altcr of Notilicati(nl <br />_l ccrlily that thc rcgulalions rcgtrding artrcslos rcnor'al arc not tfplicablc k) lhis pro.iccl. <br />I ccrr ily rcarl Ihis applicrtion anrl lhc illx)vc itrli)r rn.li(in is corccl I agrcc l() cotnply with illl ('ily rn(l (i)unly <br />ordirtanccs rclaling k) bu rcprcscnlativcs ofthis Cily and County k) cntcr uF)n tlrc <br />Applicrrt or <br />It'rrritm <br />li)r <br />and <br />U v'Y1v{-CLLi\--- Cr <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVl nsu lation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />lvlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif. <br />A <br />FINAL 3/tt /zr)-LYX",n <br />Certificate of ncy '//-/u <br />Nlotes, Remarks, Etc <br />lrnder's Namc