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BUILDING- !NSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNI'R IIUILDER DEI-CARATION <br />I hcrcby illlirm undcr pcnnlly ol pcrjury lhal I anl cxcnrpl fft)trr lhc Onilraclors' l.iccn\c Law frrr thc fblkrwing rcasirn (Scc.7031.5 <br />llusincss lnd I'rolcrsion Codc): ADy Cily or Counly which rcquircs r Ernrit to conslrucl. ollcr. infrovc. dcnx)lish or rcpair ilily <br />slruclurc. prior Io its issuailcc. illso rcquires thc applictrnl for such lrcrnrit to lilc a signcd statcilrcnt thrl hc or shc is liccnscd pursuilnl <br />lo thc provisbns ol-lhc Contrrcbr's Liccnscd hw (Chaptcr 9. Conrnrcncing wilh Scclion ?(Xlo oi Division 3 of thc Busincss and <br />I'ro[cssionsCodc)orlhalhcorshciscxeDlJillhcrcfromflndlhchrsisli,rlhcxllcgc(lcxcnll)lioil. Atryviol{tionoiScclionT0.]l.5bytny <br />rpplicnntli)rapcrnlitsubjcctslhc ilpplicantk)acivilpcnaltyolnotmorcthnnlivchundrcddollars(S5(n). <br />-1. <br />as owncr of lhc propcrly. or my cmployccs wilh wcgcs ns thcir \olc coilipcnsal i()n, will do thc work und thc structure is not <br />inlen(lcd or ofltrcd lbr qlc (Scc.70.l.l. Business and l'rofcssions C]odc: The Contrack)r's I-icensc Law docs nol upply h xn owncr of <br />lhcpropcrly whohuildsorinlx)v€slhcrcoil.ilxlwhod()cssuchworkhinrsclfr)rhcrsclforlhroughhisorhcrowncntphyccs. <br />l)rovi(lcd lhrl such irilprolcnttrls arc nol irilcfilcd orollcred for sah. ll. hoscvcr. lh( huiklirrg or improvenrnt is \oH wilhin (ntc )ril <br />srlc ). <br />-1. <br />as owncr ol thc Propcrly. rnr cxclusivcly c(nilracting wilh liccnsc(l conlrackrrs lo construct lhc p()iecl (Scc. 70l.l. Busirrcss <br />oM Pn)fcssi)n Codc: l hc Conlrnclor's l-iccnsc Lnw doc\ trol rpply lo an ()wncr ofprrrpcrly who buildr or inrproves thcrcon. <br />rnd who conlrilcl\ tbr such projcct\ wilh a Corilrnctor(s) liccnsed l)ursurnt lo lhc (i)nlrirck)r's Liccnsc l,ilw)- <br />_l ilrn cxcmpl undcr Scclion_. ll. & P.C. li,r this tcrsoo. <br />Dale:_ __ ownerl <br />lVO RK E RS' C( II\I PENSA TION <br />NECLARATI(IN <br />l hcrchy allirnr undcr pcnaltyol pcrjuryonc of lhe lblk)wilg dc.lilrations: <br />-l <br />have and will ilrriiltuin a Ccdificillc of Cotr\cnl lo Scll:lnsurc f()r workcrs coilrl)cnsation. as providcd Ii)r hy Scction l7U) of thc <br />hkr Codc. for the pcrli)rtruncc oflhc work tbr which lhc pcrnrit is is\ucd. <br />-lhavcandwillnrainlxiDworkcrs'cofllpcnsalioninsurancc.x( <br />rcquirc(lhySccti()nJ7(X)ollhct,ahorCode.li)rlhcpcrlirrtnnccol <br />lhc work lin which thir pcrnrit is issu(I. My workeN coilll)crlsiltioD insurrncc canicr antl 1x)licy nuillhcr luc: <br />l'olicy Nu <br />I ccnily that in thc Jrrl(,rmrilcc olthc work l'or $hich rhis fcrnril is issucd. I shrll not cnlploy rny Nrson in any manncr <br />so as lo bcc()illc subjcct t) lhc workcrs'cotrrl)cnsation Iaws ol Crlilbillia. rnd dgrcc lhal il I should bccomc subjcct k) thc <br />st)rk('r\' conllcilulion provisions ol Scclion -17(I) ol lhc [-rtnr C{xlc. l shrll. lorthwith conrPly wirh tho(c pft)!i\ions. <br />WARNINC: Ftrilurc lo sccurc workcrs'conrpcnsalir)n coveragc is unlawlul. nnd shrll suhFcl nn cillpk)ycr lo crirninal Jrnilllics nnd <br />Sccli(n .1076 of lhc l-ak)r (-odc. irilcrcst and atk)rncy \ l-ccs. <br />l)rlr: <br />-- <br />Appliont: <br />t,ICI!NSED CONTRACl'()R <br />DECLARATION <br />I hcrchy alllrm under l)cnally ol pcrjury lhat I anr liccn*d undcr provisio0 of Chilpler 9 (conrnrcncing with Scclion 7(X)0) ol Divisior 3 <br />of lhc Busincss and Prclcssi()ns Codc. an(l mv Iiccilsc is in full lorcc {nd cffcct. <br />l-iceilsc <br />Dale: <br />-iccnsc Nunlhcr: <br />C0Dlra(krr: <br />CONSTRUCTION LITNDING AGENCY <br />I hcrchy aflirm under lttrtlty of pcrjury lhrl lhcrc is il conslrucli(nr lcnding nScncy li)r lhc pcr[orn]nncc o[ thc work for *hich this Jrrmit is <br />issued (Scc. .1097. Civ. C.). <br />I rndcr'\ A(ldrc\\ <br />APPLICAN'I DECLARATION <br />I hcruhy allinn umlcr pcnalty of Ircrjury onc of lhc folhwing dccltrrtrtions: <br />DcmolitioI Pcrntits-Asbcstos Notillcxtion l:cdcrnl Rcguhlions ('l'itlc 40. I,iln6) <br />_Rcquircd Lcttcr of Notilicxtion <br />_l ccaily thill Ihc lcdcrnl rcgulillioils rcgilrding rstrsk)s rcrnoval rrc n(x npplicahlc to lhis proicct <br />-l <br />cctrify lhal I hnvc rcild lhis ilpplicalion ilnd sltlc thnt lhc akrvc inlirrnut ion is corrcct. I igrcc to cotnply with illl City and Counly <br />ordinnilccs ilDd Slrlc [ilws rclatirrg to building conslrucli()n. ud hcrchy authorizc rcprcscnlnlivcs oflhis Cily lnd County to cntcr upoD tlrc <br />abovc n)cnlioncd propciy li)r iDspcction purposcs. <br />Apl,licilill or Agcnl SigDalrrrc: <br />Prnrilce naDe (prinl): <br />Ih(r: <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/Vent/l nsu lation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />[/lasonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />FINAL /-/f-t? ,J)e{d-(9 <br />Certificate ol Occupancy <br />Notes, Remarks, Etc <br />(:uri.r <br />lrndcr's Namc: