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SITE.WORK DATE ID/SIG.COMMENTS <br />Set Backs \ <br />Forms/Steel/Holdowns /:I tre w I) <br />Erection Pads -r\il <br />UFER Ground I ,\\' '/ ar,v\JSLAB Floor / <br />Su bfloor/VenUl nsu lation <br />Roof Sheathing -),t -.W,a ^ ^rnId&1-L l(lu-,/t7)/Shear Wall ( <br />Framinq l-- 14-2^ ! <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath 9.Zvzg r&sl /d. <br />Brown Coat <br />[\4asonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />FINAL ?-lq-z-o i *Qto, <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />BU!LDING. INSPECTOR RECORD <br />-l <br />dn exempl undq <br />DArc:.2 <br />OWNER BUII,DER DEL(]AR? <br />I hereby affirrn under pmalty ofpqjury thal I dn exernpl frorn lhe Conlractors <br />Busincs md Profssion Code): Any City or County rvhich requirc a ;vmil <br />stmclurc. prior to its issumce. also rquirB the applicanl for snch fEmil lo file a <br />to the provisions of the Conlractor's Licensed Larv (Chapter 9. Cornmcncing rvr. <br />Profcsions Code) or that he or she is exernpt thoefiom anrl the bois for the alleged e,, <br />applicantforapfinitsuhjetsthe applicanltoacivilpenaltyofnotrnorelhmfivehundrc. <br />l. o orvno ofthe prope(y. or my employs with wag6 6 lheir sle conrpensation. will do the work slrxdruc is nol <br />intqded orofferedforule(Se.T04,l.BusinssmdProfssionsCode:'fheContraclor'sLicensel,awdo6notapplytoanor\rsof <br />thc tmtEly who btrilds or improve th6@[ ild who do6 such work himself or ho*lf or through his or ha orvn ernployee. <br />provided that such improvqnmts tre not intmded oroffqerl for sale. lf. howfltr. the building or improvemot is mld within one yw <br />ofcomplaion. the Owner Buildq rvill have the burdo ofproving tha hc or she did not build or improve the propsly for thc purposof <br />salc). <br />_1. m orvns oflhe propely. m exclusively contracling with licensed contractoN to construct the pojed (Sec. 7044. Ilusins <br />md PrclcsionCodc:TheContractor.sLiceoscLawdo6nolapplytoaorvnrofpropeflyrvhobuildsorirnpro{eslhq@n. <br />and who conlracts for such prcjms with a Contractor(s) licensed puGuant to th€ Contractor's License Larv). <br />4 <br />lirr <br />I hereby aflirm undo penalty <br />DIi('I,AR 'I'ION <br />follo* ing dcrlaratitrrs: <br />_l have md will mainlain a Cenificate of Consmt to Self-lnsure for *orkers' conrpensation, a provided firr by Srtion 3700 of the <br />Labor Code. for the psfomroce of the work for rvhich the pmnit is issued. <br />_l have and rvill rnainlain workers' compeNalion insurance. as required by Section 3700 ofthe l-abor Codc, for tlre polonnmce of <br />thc rvork for which this pemit is issucd. My workers' conrpensation insurance cmier md policy nurnber ae: <br />Policy Numbq: Expires: <br />_l cc(ify that in the pcrforillance of the work for lvhich this permil is issucd. I shall nol cnrploy any person in any Inanner <br />m m to become subjat to lhe workfls' comfBsation larvs of Califomia. dd agr€ that if I should beconle subjel lo lhc <br />uorktrs'conrpmsationprovisionsofSeclion3T00ofthel,abor('ode.lshall.forrhwithcornplywiththoseprcvisions. <br />\\'ARNINGi Faihrre to sure \i'ork6' <br />civil fincs up to one huildred thousand <br />covmgc is unlawful. md shall subjet in to oiminal perultis and <br />dollars in adrlition to cost of m providccl for the <br />Strtion 1076 otthe Labor Code.and <br />I)t,.( t. \tt,\ I l()\ <br />I hereby affinn unda pcnalty ofpojury I nill provision ofChapto 9 <br />of thc Businas and Profcsions Code, md my license is in full force ild eflect. <br />2-oq-/ <br />Sfftion 7000) of Division 3 <br />License <br />Drte: <br />Clm:-License Numbo: <br />- <br />Lende('s Addrs: <br />Con(raclor: _- <br />CONSTRUCTION L1]NDINC AGENCY <br />I hreby affinn unda poalty of psjury lhal thse is a comtruclion lelding agmcy for the pqfonnance of lhe work for rvhich this pornit is <br />issued (Ss. 3097, Civ. C.). <br />l-ender's Nilrne <br />APPLICAN'T DECI ARATION <br />I hotby affrnn undo penalty ofperjuy one oflhe follorving deluations: <br />Demolition Permits-Asb6tos Notification Federal Regulalions (Title 40, l'art6) <br />-Requircd <br />Letts of Notilication <br />ro this pruject. <br />a8re to comply wilh all City and ('ounty <br />ive of this ('iry and Counly lo entcr upon lhe <br />Da(e: