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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS ()WNER BUILI)ER DELCARATT0N <br />I hcreby illfirnr undcr pcnnlty ol pcrjury lhal I ailr cxcilrpl frorn lhe Conlrrck)rs' Liccnsc law for lhc lolk)wilrg rcasoD (Scc.70-11.5 <br />Busincss and Protcssion Codc): Any Cily or Counly which rcquircs r pcrnrit k) construct. illtcr. inrprovc. dcnrrlish or reprir any <br />slnrclurc. pri()r lo ils issunnce. also rcquires lhe rpplicanl li)r such lErtrril lo lilc a signcd stalcnrnt lhnl hc or she is liccnscd pursudnt <br />lo thc provisions of thc Conlracbr's l-iccnsed [-aw (Chaptcr 9. Connncncing lvith Seclion 7(Xn of Divisi(,n 3 ol thc Busincss and <br />ProlcssioDs(i)dc)orlhxtheorshciscxcnlpllhctclionlandthchasisli)rlhcxllcgedcxcnrpli(,n. Anyviolilli(mofScclionT0ll.5hyany <br />applicilntlorilpcrmitsubjcctsthc nppli.anttoacivilpenaltyolnotn()rcthilnfivchundrcddotlilrs(5500). <br />_1. as owncr of lhc proFrcny. or rny etrrployccs wilh wagcs as lhcir solc corapcnsalioil. willdo thc work and thc slructurc is not <br />iilcndcd orollcredlirrslc(Sr.7(M4.BusirrcssandProfcssiolsCodc:ThcContrack)r's[-iccnscLflwdocsnolapplytoanowncrof <br />thcpmpcny whohuiklsoriillprovc\thcNn.rNlwhod@ssuchworkhinrsclforhcrsolforthroughhisorhcrownetrrployccs. <br />providcd thal such inrprovctrrnls m nol inlcndcd orollcrc(t for salc. I1. howcvcr. the building or inrprovctrrnt is sold withir onc )ur <br />of conylclhn. thc Owncr Buildcr will hnvc lhc burdcn of proving lhat hc or shc tlid not build or improvc tlrc !()Jrcfly for thc purfns oi <br />salc ) <br />-1. <br />ns owncr ol lhc l)rofcrly. arn cxch\ivcly cottracting wilh licctscd conlrxcl(i's lo co0struct thc p()jccl (Scc. 70.14. Bnsirrcss <br />an(l Pnrla'\siil(bdc:'lhc(iinlrtct()r'sl-icen\cl-a$'d()esnr)lipllytornollncro,l)ropcrlvshohuiLhorinrprovcsthcrcon. <br />and who conlracls lbr such pr()iccls wilh il f\n{hch(s) liccnsc(l pursilrnl lo lhc (inilrack)a\ l,iccilsc l-aw). <br />_l atrr cxcnun un(lcr Scclion_. B. & I'.C. ti)r this rcrson. <br />Datc: <br />- <br />Owner:- <br />WORKERS' CONIPENSAl'ION <br />DFCLARATION <br />I hcrchy allirnr undcr pcnally of pcrjury onc ol lhc li)lhwing dcclarntions: <br />-l <br />hovc imd will nlilintain a Ccrtilicalc of Corscnt kr Sclf-lnsurc lbr workcrs' coDrpensation. as prcvidcd for by Scctiotr l?00 ol thc <br />kbor Codc. for thc pcrlormancc of thc work lor which thc pcrmit is issucd. <br />?S havc and will nraintrin workcrs' competrsrlion in\urancc. as rcquircd by Sccttr)n J7fi) oflhc hbor Codc. for thc pcrformancc ol' <br />thc work for which this pcrnril is issucd. My workcrs' conrpcnsation insurancc canicr and policy nutnbcr arc: <br />,^".,, Tftlp Fv'-Q- <br />Policy Numhcr:o8'O/-lOrR <br />-l <br />ccf,ily lhat in thc performancc of thc work for which this pcrnrit is issucrl. I shall not cnlpkry rny pcrsoil in nily nlailncr <br />so ns to hccoilE subjccl to lhc workcrs' compcnsation laws of Calili)rnia. and ilgrcc I hal if I should bcco[rc suhjccl to tlE <br />workers'compcnsalionprovisionsofScclionlTfi)ofthcl-atnrCo(lc.lshflll.ti)nhrvithconrplywithlhorcprovisions. <br />WARNING: frilure to sccure workers'conlpcnsation covcr0gc is uilLiwtirl. and shull suhjcct rn cnrploycr lo fritrrinal fEnaltics and <br />civil llnc\ up to onc hundrcd lhousand dollnrs (Sl(X).fiX)). in addition k) thc cost ofcornpcnsation. danugcs as providcd for thc <br />scclo,r .{,7h r,t tnc l,xmr \ (rcc. nilcrc\t uno xttorncy s tcw-- <br />o*", June l?, ?9t$ nrr,,o*,,6 <br />LICENSFI' C(INTRACTOI-- -./ <br />DECLARATT(IN <br />I hcrcby nlllrtl undcr pcnahy of Frjury lhat I rm ljccnsd undcr provision of Chaplcr 9 (cornnrncing with Scction 7(X[) ol Divisim 3 <br />ol thc Busilcss and Profcssions Codc. nnd nly licensc is in lull li)rce and cftcct. <br />l-iccnsc (3 - c.z /3/ 5rg <br />oare,Jr.r*.a- f + aa$, contractorK f <br />CONSTRUCTION LENDING AGENCY <br />Ihcrebyaffirnrundcrpenallyofpcrjurylhatlhcreisaconslructionlcndingagcncyfortheperfornranccoflhcworkforwhichthisprrritis <br />issucd (Scc..3097. Civ. C.). <br />[-cilder's Namc: <br />lrrtlcr's Addrcss: <br />APPLICANT DECLAN,4,'I'ION <br />I lmby allinn undcr lEnally of pcrjury orc ol-lhc folk)wing dcclilrations: <br />Dcnmlilion Permils-Ashcslos Nolification Fcdcral Rcgulalions (f itle 40. Part6) <br />-Rcquircd <br />l,ettcr of Notifi calion <br />_l ccrli[y lhill thc lcdernl regulalions rcgrrling ashcs()s rcrnoval nrc ilril npplicnhlc k) lhis pfl)jcct. <br />_l ccrlilylhrllhtvcrcul lhisrl)l)licali()nrindslrtcthxl lhciltx)vcinlbtnrili()niscoflcct.l r8rcc lo conlply <br />i!cs oflhis Cily <br />with all Cily and Counly <br />()rdiililncc\ and Sttlc l-aws rclxting I() buikling and Counly to cnlcr u[x)n thL <br />ntn)vc rftnlioncd proltrty li)r inspccli()n <br />ApplicanlorAgcntsignutu*. ( <br />Pemrite nsme {prinl): <br />hcrcby aulhorizc rcprcscntal <br />,rrr" Jv.<. /X U? <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenVl nsu lation I /,1 <br />Roof Sheathinq o/hl /q.J-arz lrl* le*- -^ <br />Shear Wall t,-o \ <br />Framino <br />lnsulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />lVasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />FINAL 3 {2-%/P -9rl//rZ) <br />Certificate of Occupancy <br />Notes, Remarks, Etc <br />-a