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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE IDiSIG.polvul/IENTS OTVNER BI.III,DER DEI,CARATION <br />I hcrrlly allinn undcr pcnilty ol pcrjury thrl I am c\cnrpl liom lhc Conlrack)rs' l-iccnse Law li)r lhc ,i)ll(]wing rcason 1Scc.7(]31.5 <br />Busincss arrrl Prof'cssiD C(rlc): Any City or Cornly whieh rcquires a lErnnt lo constnrcl. alter, improvc, dcft)lish or rcpxir rny <br />stnlcturc,prk)rk)ils issuancc.alsorequircsthcapplicantlirrsilchl^*nnitkrtilcasrgncdslatcmcnt thrth('orshcisliccnscd pursuant <br />t) thc pr)visi(Ds of thc Contrrck,r's l-iccnscrl Law ((haplcr 9. Commcncirg with Sccti(ilI TUX] of Divisir,n .l of thc Busincss and <br />ProltssionsCoJc)orthatheorshciscxcnrptthcrclionlilndlhchasistilrthcallcScdcxcmplion. Anyvt)hlx)nofScction70.ll.5hyany <br />alplicrntli)raNrmilsubjcctsthc applicantklaeivilpcnrllyofnotmorcthanlivchilndrcddolltrs($5(n). <br />_1. a\ owncr ol lhe proFdy. or mv cmployecs with wapcs ns lhcir solc comltnsrli(trI, willdo thc work ilil lhc struluc is nol <br />iilcrklcd orollcredfi)rsdlc(Sce.T044.RusincssanrlProlissrrrsCrxle:ThcCoDtractrr'sLicensc[-awdocsnolapplyk)anowncrol' <br />thc pn)ltfly wtx) builds or inlprovcs thcB)n. axl wln) drrcs \!ch wort himlcll'or hcrscll or throuSh his ()r h('r own cnrpbyccs. <br />providcd lhat such improvcnrn(s m ftil iilcndcd orofl!:rcd li)r snh. Ii howcvcr. thc huilling or inrpnrvcnrnt is soll within onc ycu <br />ol eonrplcli(,n. thc Owncr Buildcr will ha\c thc burdcn ol proving that hc or shc ilid not build or improvc lhc pn)fEdy li)r thc purlx)sc ol <br />s{lc). <br />_1. rs i)wDcr ol thc profcny. anr t-rchlsivcly contrr(li[g wilh liccDscd conlrack)rs l() consnlct thc piiccl (Scc. 7044, Buslrr'ss <br />rnd l,trlc:ssrrrCode:'l'heContrrctor'sl-iccnscLawdocsn()lapplyloanowncrofprolrcrtywhohuilds()rinprovcsthcrcon. <br />and who coDtracls lix such projcct$ wilh a C(nilrick)(\) liccnscd pursurnl kr lhc C()nlrnck)r's I-iccnsc l,aw). <br />I anr crcmpt undcr Scctlon-, B. & P.C. fbr this reasori. <br />nrr har. <br />TVORKERS'COLTPENSAT- <br />DT]CLARATION <br />I herchy allirm under pcnalty of pcrjury ()nc of thc firllowing dccluations: <br />_l havc and will maintain a Ccnificalc of Conscnt k) Scl[lnsurc lbr wrrkcrs comJrensation. as pmvidcd ,br by Scction 3700 ollhc <br />tjhrr Cixlc, li)rthc l--rfomancc of lhc work lbr which thc Frmit is issucd. <br />_lhavcaDdwillmainlrinworkcrs comlrcnsati(nlill\urrnec,as rcquircdhyScctr()nJ7fi)ofthcLaborCodc.ti)rthcpcrfi)rmdnccof <br />thc work li)r which this permit i\ isrucd. My workcrs e()nlporsilion insurrDcc earicr imd fxllicy nunlbcr i(c: <br />P(,licy Numhcr: EtPircs: <br />_l ccntly that in thc pcrlbrnunec ol lhc work l'()r which this Irrmil is issuc(|. I \hrll not cmpk)y xny pcrson in any manner <br />so a( k) hcconE subjcct l() thc w()rkcrs'c()mpensatk)n laws ofCalifi)rnia. and agrec thnl if I should bccont suhjtcl lo thc <br />workcrs'comlcnsationprovisionsolSectionJT(DoflhcLatx)rC(xle,lshall,tonhwi(hcomplywilhlh()scprovisions. <br />WARNIN(i: Failure (, sccurc workcrs'compcnsalion covcragc is unlawlll. ttrd shall suhject an cnrpl)ycr k) criminal Fnallics and <br />civil I'rnL's up to onc hundrcd lhrrrsand dollars ($l(x).(XX)). <br />Sccl()n -1076 ol lhc Lalx)r Codc. rnlcrcsl aDd alk)rn('y \ li'cs. <br />in rdditril lo lhc (r)sl of irlr. rJanragcs rs p()vidcd lirr lhc <br />pEc@LlaN <br />, I hcr_chy illirm under Fcnrlty ot pcrjury that I am liccnrd undcr provision ofChaptcr 9 (commncing with Sccti(,n 7U)0) of Division -l <br />/41/ ,n" Busrncss and P()l'cssir)ns Code. ud my liccnsc is in tull li)rce Md cltcct.7t <br />I -iccn\c <br />CONSTRUCTION LENDING AGENCY <br />I hcrchy rllirm undcr pnalty ol Frjury that thcrc is a constnrclion lending a8cncy li)r thc pcribrmncc of lhc work 1()r which this Frmit is <br />issucd (Sec. .1097, Civ. C.). <br />l-cnrlcr's Nrnrc <br />I.cmk'r'\ A(irlrcss: <br />APPLICANT DECLARATION <br />t IEL..hy alliml undcr pcnrlty ol p!rjury one ()l thc li)lk)wing dcclxrati(rrs: <br />Dcnxrlilion Pcrni(s-Ashcstos N(ililicati()n Fcdcral Rcgulattrns (Titlc 40. Ptn6) <br />_Rcquircd Lxttcr ot Notil'i(dti(rl <br />_l c('rtily that thc lidcralrcgulaltr,ns rcgeding ashcslos rcrnovalec nol rpplie al)lc t) lhis pmjcct. <br />_l ccrllly lhrt I havc read this rfllicatiur and stllc lhal lhc rlx)vc inli)rmalion is corccl. I aSrcc lo comply with all Ci(y and County <br />odinrilrc\ r,trl Strtc [,rws rclnling l() huilding conslnrclxrn. rod <br />ahov(' nrcnlioncd propcrty li)r <br />Applicrrrl or ARenl <br />Pentri(ec nailrc <br />rcprcscnlalivcs of this ci(y {nd county lo cntcr uFrn lhc <br />Set Backs ^l ,lR &b@^b <br />Forms/Steel/Holdowns tl ',2, <br />Erection Pads .- f'r(iY <br />UFER Ground <br />SLAB Floor <br />Subf loor/Vent/l nsulation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Cefiif <br />,I -<\ <br />FINAL q t+t9 7r/1,/ <br />Certificate of Occupancv tl Il <br />ti <br />Notes Remarks Etc.w-/ <br />,^n, //21/r? <br />I)xlo r/*/ z <br />I <br />'4.t'-t <br />//t(/