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BU!LDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG COMMENTS OIVNER BUILDER DE],CARATIoN O <br />I hcrchy allirrn undcr l)cnrhy ol perjury lhat I anl cxctrrpl f()nl lhc Conlraclors Liccnsc Larv li)r Ihc folk)wing rcason (Scc.7031.5 <br />Bu{incss lnd [,rofcsshn C(xlc): Atry Cily or Counly ivhich rcquires a pcrmil lo conslrucl. {llcr. inrprovc. dcrxrlish or rcpair anv <br />shrcturc. prior lo its issuarcc. also rcquires lhc applicant li)r slch lrcrnrit b lile a signcd slatcnlcnl lhrl he or shc is liccnsed pursuanl <br />to rhc proviqions of tlrc Contrack)r's Liccnsed Law (Chnplcr 9. Comnrcncing with Scction 7(XX) of [)ivision .1 of thc Busincsr and - <br />I,rolcssi('nsCodc)orthatlEorshciscxenlptthcrcliomandthcbasisli)rthcnllcgcdexcmfli(,n. AnyvioliilioilofScclioilT0ll.5byatry <br />ilpplicanlfornfcrnritsuhjcctsthc upplicrnlhccivilpcnaltyolnoln()rclhrnfivchundrcddolltrr(($5(X)). <br />_1. as o$ ncr of lhc p()lrrly. or my cmpkrlcc\ s'ilh wilgc\ as llrcir \()lc conrlrcn\rti()tl. u'ill d(, llrc lvork md lhc sltululc i\ nol <br />thcpK)ncf,y wh()buil(lsorirnprolcslhcrdnr.andwhodocssuchlvorkhitrlsclIorhcrsclforlhroughhisorhcrowncn4kryccs, <br />salc). <br />_1. rs otr ncr ()l thc l)ropcrly. anr cxclusivcly conlrilctiig wilh licct(c(l c()ntrrclors lo coDslrucl lhc frojcct (Scc. 704,1. Burittcs. <br />nnd [h)ltssi(n](i)dc:'[hcContrnclor'sLiccnscl-ilwdocsnolilpplyloilnowncrofpropenywhohuiklsorimprovcslhcrcoil. <br />nil(l $lnr contrncl\lbrsuchpruiccl\silha(i)rilrrclor(s)liccnscdpur{urnllolhc('oiltrlck)r'\LiccDsc[-as)- <br />I xilr cxrillot unJcr Sucli()il . B.li)r lhis <br />| )al e:in4 Yfls <br />I hcrchy atllrm undcr ltnilllyof pcrjuryonc ollhc 'lnrali()ns: <br />_l hrvc arxl will miiiililin il Cenilicalc ol Conscilt lo Scllilnsurc for workcrs compcnsation. rs providcd li)r by Scclion lT(x) ol lhc <br />Llh)r C(dc. lbr lhc lrcrtbrtnilncc of the work lbr which lhe pcrmil is issucd. <br />_l havc and will trriitrtrin workcrs compcnsatioD insurrncc. as rcquirc(l by Scction -1?0O ol lhc Lahor Codc. l-or lhc pcrfonnancc of <br />lhc work ti)r which lhis fcrnlil is issued. My wotkcrs' cornpcnsali(D insurrncc caricr urd policy nunrbcr arc: <br />Policy Nufirbcr: Expircs <br />_l ccrtili lhilt in thc pcrfornHrcc ol'lhr work for which lhis pcrnril is issucLl. I shall nol cntpkry any pcrson in any trlanncr <br />so rs t() hccotrrc suhiccl k) lhc workcrs conllcnsali()n lilws ol-Ctlilbnlir. ilnd rgrcc thrl if l shoul(l hLconrc suhjccl h lhc <br />r\()rkcr\'!oiltpcnsarionprorisionsolScction.lT(X)ofthc[-atx)r(ixlc.l\hnll.lbrlhwilhcon]t)lywilhlho\cfrovisi(ins. <br />WARNIN(;: fiailurc k) sccurc srrrkcrs'cortpcnsrlion covcragc is and shall stthicct rn cnpkrycr h (Tirililrnl lrcnrllics and <br />civil llncs np lo o[. hun(lrc(l thou\ilrtr| (k)llrrs ($l(X).(Xx)). <br />Sccliofi .1076 ol lhe l.alxI Co(lc- irrtcrcsl an(l xlkrrn.y s ltcs. <br />lo lhc ol ion. tlanragcs as pft)vi(lc(l IiI lhr <br />l)ilte:5-ttJ,K <br />I hercby rllir m rrrilcr l)cnrlty ()l pcr.itrry lhr( I ilnt provisiotr ()f ('hrplcr 9 (conriltrrcing s ilh Srclior 7(XX)) (,1 Divisir)n l <br />of thc Busincss and Profcssirrns Cotlc. antl rny licc[se lbrcc rn(l cl'lccl. <br />Liccnsc <br />Dn(e: <br />,iccn\c Nunlltr: <br />(i[(rnclor: <br />CONSTRUCTION LENDING AGENCY <br />I hcrcby rflirm under Frcnally o f pcrjury that thcrc is a c(nrst ruct ion lcndin8 agcncy for lhc l)c.forma[ce o[ I hc work for which lhis fErmil is <br />issucd (Sec. -1097. Civ. C.). <br />l-crxlcr'\ Nilnrc: <br />Lcndcr's Adtlrcss: <br />APPLICAN'I' DECLARA'IION <br />I hcrchy amrilr un(ler pcnrlty ol pcrjury onc of lhc lirllowing dcchrations: <br />Dcnrolition Pcrillits-Ashcstor Nolificrtio[ l;cdcral llcgulalions ( Iillc.10. Pflrl6) <br />-Rcquircd <br />[xllcr of Nolificali(nr <br />-l <br />ccrtify thal thc fcdcral rcgulations rcgarding asbcslos rcrnoval rrc not applicahle lo lhis piojecl. <br />_l cedify thnt I havc read this applicalion and slalc thal lhc iltnvc inli)nnation is corecl. I agre lo comply whh all Cily and Counly <br />orrlirrrnccs antl Slxtc Lru s rchting l() <br />rbo!c nlctrti()ncd prol)crly li)r inspccl <br />hcrchy xulh()ri7c rcl)rcscllalivcs of lhis ('ily nn(l County lo cntcr up(rl lhe <br />Apt)licnnl or AgcDl Signtluro <br />I'emrilee nanre (prinl):1( <br />u,r",5-lf-(tr <br />Set Backs <br />Forms/Steel/Holdowns 5-2jt4tr v.w)o <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/Vent/l nsu lation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Enerqv <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />lMasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />FINAL A-7-t/,,/ Z. 'L lN.5rq/m) <br />Certificate of Occupancv <br />Notes, Remarks, Etc. <br />( )$ [rr <br />Appliriltrl: