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BUILDING- INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG COMMENTS O1VNER BUII,DER DELCARATION <br />I hcrcby allirnl undcr pcn{lty ol pcrjury thrl I an cxcnrpl iir)m thc Contraclors l-iccnsc l-aw li)r lhc li)llowing rcason (Scc.70-ll 5 <br />Busincsr and Prolcssiut Co'lc)i Any City or Counly which rcquircs a lErmit lo cotrstrucl, {ltcr, imfrovc, dcm)lirh or rcPrir any <br />stnrctrlrc.priortoits issuancc.alsorcquiresthcafplicanllirrsuchJrcrnritk)lileasigncdstalcmcnt thathcorshcisliccnscd pursuanl <br />to thc provisions ol'thc Contrackrr's Liccnscd Law (Chxptcr 9. Commcncing with Scclion 7fiD of Division -l of thc Bu\inc\s and <br />P()ftss()nscodc)orlhrllrcotshciscxcmPtlhcrclionldndthcharislbrtheallcscdcxcmplion Anyvi()latbnofst'cli{)n7011'5hy'ny <br />applicantlbr!f^-rtrlitsuhjcctsthc applicdntk)acivilpcnrltyol'notmorcthanlivchumlrc-rldollars(S5U)). <br />_1. ac owncr i)l thc prolxr1y. or nly cnlployccs with wagcs a\ lhcir solc conrpcnsrtion. wdl do lhc work ukl the slK*tm L\ n()t <br />iilcndcd orotltrcdlirrsalc(Scc.T044.BusincssandProtissionsCrxlc:-lhcGxlrack)r'sl-iecnscl"awdocsnolapply()rnowncrot <br />lhcpn)lErty whohuikh()ritnprovcsthcrcon,Mdwh(,dr)cssuchworkhin]\clforhersclfortlrroughhisorhcrowncmpl(lyccs. <br />provided th{t such itrrprovcnrcDt\ itrc not intcndcd orollcrcd Ibr salc. lf. howcvcr. thc building or improvcmnt is sold within onc ycu <br />ofcoilplction. thc Ow0cr Iluildcr will hlvc thc burden of pr)vtrr8 llnl hc or shc did nol huikl or improve lhe pmpcny tbr lhc pufx)sc of <br />salc). <br />_1. as owncr ol thc proncrty. anl cxclusivcly conlraclinl wllh liccnscd contractr)rs tr consllllel thc projccl (Scc. 7044, Busrrcss <br />ad PDllssiu Coilct 'fhc Contrtck)r's Liccnsc l-aw d()cs n()l npply b rn owner ()l prolxrly whr) huilds or imPr()vcs lhcrc()n. <br />nnd wh() c0ntracls lilr such pn).iccls wilh a C(nilrrclr,(\) liccnscd Pursuant k) lhc Conlracktr'r Liccnsc [:w). <br />_l am crcmpt undcr B & P.C. li)r lhis reason. <br />Dalei- <br />WORKERS' CONIPENSATION <br />DSCIABAIX}N <br />I herchy allirm undcr pcndlly oi pcdury one ollhc li)lk)wing dcclffalions: <br />_l havcam!will maiilainaCcilil-rcatcofConscnttoscll:lnsurcfi)rworkcrs'compcnsalit)n.as providcdli)rhySection-UU)oflhc <br />I2tx)r Gxle. lbr lhc pcrli)rmnncc ol thc work ti)r which thc Ftrmil is issucd. <br />_l havc anrl will maintni[ workcrs compcnsati(]n insurancc. as rcquircd by Scction -17(n (][lhc ljtx)r Code. for thc lrrl(]mancc of <br />thc work t{)r which this lrrmit is issucd. My workers' compcnsati()n insurance caricr ilrl Fx)licy nunrher ilc: <br />Prll( v Numhcr: Ernirc*: <br />- <br />_l ccnily thrl in thc pcrlhrmancc of lhc work li)r which thi\ pcrnril is issucd. I shdll n()t cntpkry any pcrson in any manncr <br />so us b hccomc suhjcct lo thc workcrs'compcnsatirxr laws ofCalilornia. and agrce that il l should hccomc subject k) lhc <br />workcrs' compensalir)D provisions ofscclion l7U) ol lhc tJh)r G)dc. I shall. tbrthwilh comply with thorc proviri{}ns. <br />IVARNING: Failurc lr scurc workcrs <br />civil fincs up to onc hundrcd lhousrnd <br />comfrcnsati(m covcraga is unlawftl. and shall subjccl an kr crrminal 1^_nrllrs antl <br />dollrrs (SlU).{xX)). r[ rdd(r)n k) thc eost ol as providcd li)r lhc <br />Scetx)n ll)l(r 0l lhe l.rli,intcrcst and alt)rncy s ltcs. <br />I 7 <br />DEC:LARATION <br />I hcrchy alTirm unrlcr pcntlty ol pcrjury that I am liccn*d unttcr pn)vision ()fChtptcr 9 (comnlcncinS with Scction 7000) of Division l <br />of lhc Busillcss ind lkrltssions Code, md my liccnsc is in Iill l()rcc and eftccl. <br />[-iccnsc <br />tl <br />CONSTRUCTION LENDING AGENCY <br />I hcrcby allirn undcr frcnalty ol pcrjury lhat thcrc is a construction hnding agency t)r lhc Jrcrlirrmancc of thc work lbr which this lErmit i\ <br />issucd (Scc. -1097. Civ. C.). <br />lrnder's Namc: <br />lrndcr's Addrcss: <br />APPLICANT DECLARATION <br />I hcrcby aflim undcr penalty oI pcrjury one of thc li)lk)wiil8 dccluati(ns: <br />frcfr)lilion Pcrmits-Asbcstos N()tification Fedcral Rcguhlx)ns (Titlc 40. Pd6) <br />_Requircd tf,tlcr of Notilicat()n <br />I cedily that lhc li'dcral reSillali()ns rcgrurJirrg asht'slrts rcriloval Alc not upplicahlc lo lhis pfi)j'.cl <br />-l <br />ccrlily lhxl I hrv!- rca(l lhir afpliclti{}n ild slxtc lhnl lhc illx)vc corccl- I agrcc lo c(nrply <br />I lhis City <br />wilh all City and (\trrnly <br />oldinanccs and Stalc l,rw! rclilin8 lo buildintr rnd |) cnler ulrrn lhc <br />alx)vc nlcnliur!'d pr()lEI1y li)r <br />7Applicant or AEcnl <br />Pemile name (priDalt- <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/Vent/l nsu lation <br />Roof Sheathinq <br />Shear Wall <br />Framing <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 Certif <br />FINAL ?Z?4oza J)c{ab vo <br />Certificate of Occupancy <br />Notes, Remarks, Etc.