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BUILDING. INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG COMMENTS OWNER BI-IILI)ER DEI,CA RATION <br />I hcrchy aflirm trndcr pcnally ol fe{ury that I ililr cxcilrpt lionr thc Contrnclors Liccnsc Law iirr thc followirtg rctson (Scc.7o-]1.5 <br />Busincss and Profcssion C(xlc): Any City or Counly which rcquilcs a Jrcrnrit lo co[slnrcl. nllcr. in]ltrovc. dcnxrlish or rcpair any <br />stnrcturc.priorhits issurncc.alsorequircsthcapplicrntli)rsuchfErnrilk)lilcasiSncdslatctrrcnl thrlhcorshcisliccfl\cd pulsuaDl <br />lo Ihc prol,isions oflhc Contractor's l,iccnsed [-aw (Chaplcr 9. Comnrcncing wilh Section 7(XI) of Division -l oflhc Business and <br />ProfcssionsCodc)orlhalhcorshciscxcnlFthcrclronlnndthchasisforlhcrllcgedcxcmplion. AnyviolationofScclionT0.ll.5byany <br />ilpplicanttbrupcrnrilsuhjeclslhc rpplicanlt)ilcivilpcnallyolnoln$rclhilnfivchufdrc(tdollars(S5(X)). <br />_1. as owncr of thc pi()lErly. or nly cnlployces with wilgcs rs lhe ir solc corlrpcrlsnliorr. willdo thc work and tlrc sltuclure is ilol <br />iilcndc(l or oflcrcd k)r salc (Scc.7(H,1. Busincss and Prolcsskrns Codc: Thc C()nlractor's Liccn\e l-aw docs D(il apl)ly lo fln osDcr ol' <br />thc pnlfray who builds or inrpmvcs th(E)n. afrj wh() d(rcs such rvork hintsclfor hcrscll or through hir or her own cntl)loyccs. <br />providcdlhstsuch iitpr(,venrilsitcnolillcndcdorollcrcdlorsrilc.lt.howcvcr.thcbuildingorinrprrvcrlrnlissoklsilhinoncycar <br />ofconutcliur. lhc Owncr Buiucr will halc thc hurdcn of proving that hc or \he did nol huild or inl)row thc pR)lffiy for thc puqns o[ <br />vth). <br />_1. ns owncr ol'thc Jnrrpcrty. anr cxclilsivcly conlrilciirg wilh Iiccnscd c()nlrilclor\ k) con\lnrcl lhc projccl I Scc. 7(14,1. Bttsnr:sr <br />an(l [\]ltssi(n('odc:'fhcC()nlractor'\Liccn\c[,rwdoc\ilotnpl)lylornos[cr(!lpropcrlywhobuiklsorintprovcslhcrcoil, <br />in(l wh() c()[lrrcts li,r such |x()jccls wilh n Corilraclor(s) liccnsc(l nursuaill lo lhc Conlritck)r'r Liccnsc Law). <br />-l <br />rm <br />Dsle: <br />B,&thi\ <br />()rriler <br />I hcrchy allirrtundcr fcnxltyol'pcrjuryonc ol lhc iotts <br />Lrhor Codc. ti)r thc pelli)rmancc of lhc work tirr which lhc Pcrmit is i\su(i. <br />_lhlvcrrdwillnlniDtiinworkcF'coirpen\ali()ninsurancc.rs rcq[ircdbyScclionJT(X)ofthc[.ah()rC(xle,li)rlhcpcrfortrrnccol' <br />thc work for which this pcrnlit is issucd. My workcrs' conlpdtsnlion insurancc canicr and lmlicy nunrhcr rc: <br />Policy Numbcr ExJ,ircs: <br />I (cf,ily lhrt in lhc pcrlirrnrancc o[ thc work lirr which lhis lrcr rilil i\ i\sucd. I shrll nol ctrUloy ony pcr\on in nny nlanncr <br />ro a\ to hcconr suhject to thc trorkcrs'coilUcn\nli()n h\'\ ol ('rlili)nrii. nn(l agrcc lhnl il l shonkl hccotrc snbjccl l{) lhc <br />crlil linc\ up lo (nrc hun(lrc(l ihousand dollar\ (Sl(x).o(X)). in <br />Sccti(nr J076 oI lhc Lltxlr (i)dc. inlcresl nn(l nll(ilrrcy's fccs. <br />ttarnagcs as pr0vi(lc(l ti)r thc <br />I )illr:6_rtrt Aptrliunl: <br />prcvisi(,n (tl Chal)lr'r 9 (coilrnrcncing wilh Scclion 700{)) of Division .1I hcrchy {lllrnl un(lcr pcnally ol f[rjury lhal I iln1 <br />ol' thc llusi,lcs\ ind l)rolt\si()ns Codc. trn(l nly liccnse Iirll lincc nril clltcl. <br />Lirrn\c <br />I)nl0l <br />-i(cD\c Nilnrbcr: <br />( 0nlra(lor: <br />CONSTRUCTION LENDING AGFNCY <br />I hcrchy alfirrn undcr Jrcnally of pciury thai thcrc is r conslruclion lcnding dgency li,r lhc pcrformancc of lhc work for which this lrcrilil is <br />issucd (Scc. .1097. Civ. C.). <br />Lcndcr's Ndilrc' <br />I-cnrlcr's Arhlcss: <br />APPI ICANT DECT ARATI('IN <br />I IErcby nllirnl undcr lxnally ol pcrjury onc of thc folhwing dcclarations: <br />Dcilroliti{)n Pcrmils-Asheslos Nolificalion I'tdcrnl RcBuhtions ('l itlc 40. I'an6) <br />Rcquircd Lcltcr of Nolilicalior <br />-l <br />ccrtily rhal lhc lcdcral rcgulalions rcgarditrg .1hc\los rcIB)vxltrc not applicnhlc k) lhis pn)jccl. <br />-l <br />ccrtily lhnl I hrvc rcad this alplicalioil ilnd \lnlc lhal lhc lk)vc with rll City and Counly <br />flnd Counly lo cDtcr upon thcordiDxnccs and Slrlc l-ilws rclaling k) bu rrxl <br />abo!c nEnti()ncd prcpcny for <br />Applicant or Agrnt Signalu <br />l'ernrik\' trrtrre (pritrl):Ap letcg <br />o,,",{'18j{ <br />Set Backs lA <br />Forms/Steel/Holdowns 5-2'11tr V.V-fiU <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenUl nsu lation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />[Vasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />FINAL /--'? -tQ J /( -?t i tru l4r4 <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />(&a-. -