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BUILDING. INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Su bf loor/VenVl ns u Iatio n
<br />Roof Sheathinq
<br />Shear Wall
<br />Framing
<br />lnsu !atio nlEnerqv
<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 />Engineer Final Report
<br />Flood Zone Certif
<br />I I I C Gt
<br />FINAL t1 q,'7n p/#'rN al
<br />Certificate of Occupancy I
<br />Notes, Remarks, Etc.
<br />I
<br />I
<br />(r/
<br />B UI I,DI..]R DI.]I,CA RATION
<br />I hcrcby rllirm undcr lrcnally of lErjury thar I am cxcmpt lirrm lhc G)Dlrack)ff' Licrnrc Law litr lhc folkrwirg rc9mn (Se.70.31.5
<br />Busincss anl Profcssion Crxlc): Any Cily or Counly which rcquircs a lErmit lo c(rnslrucl. allcr. improvc. dcmrlish or rcpair ahy
<br />structurc, lrior to its issuancc, also rcquircs thc applicant for such lErnlil t(, filc a signcd stdtcmnt thal he or shc is liccnsd putsuanl
<br />tr thc pnrvisious of thc O)ntraclor's Liccnrcd [:w (Chaptcr 9, Commcncing with Scclion 700O of Division 3 of thc Busincss and
<br />PrrtbssionsCodc)orthathcorshciscxcmpttlErch(rmandthchasisfbrthcallcgcdcxcmption. AnyviolationofscclitnT0ll.5byany
<br />applicatrl lirr a tEmit suhjels thc applicant to a civil pctrulty ol n(tl morc Ihan fivc hurdrcd dollas ($500).
<br />_1, as owncr ol'thc propcrty, or my cmployccs with wagcs as thcir solc compensatiort, will do thc work and thc stru,*ture is not
<br />intcndcd or otl'crcd tilr salc (Scr'.7044, Business antl Prol'cssions C<xlc: Thc Contraclor's Liccnsc ktw docs nol apply to nn owncr of
<br />lhc propcrty who builds or impnrvcs thcrcrln, and who drrcs such work hintsclf or hcrsclf or thnrugh his or hcr tlwn cmployccs.
<br />providcd that such improvcrncnts are mrt intcrxlctl rlr ollcrcd for salc. If, howcvcr, thc buildiltg or improvcmcnt is sokl within onc ycar
<br />ol'complction, tlrc Owncr Buildcr will have the burrlen ol'proving that hc or shc ditl rxrt buihJ or improvc the pmJray krr thc purprse ol'
<br />salc).
<br />_1, as owncr ol'thc pnll^-rty, anr exclusivcly contracting with liccnscd contractors to construct thc projcct (Scc. 7M4, Busincss
<br />ard l'rolesskln Code: The Contraclor's Liccnsc [-aw docs not apply lo an owncr of proJrcrty who builds or improvcs thcrcon.
<br />and who contracts lirr such pnrjccts with a Grntraclor(s) liccnscd pursuant to thc Cotttractor's Liccttsc Law).
<br />-l
<br />am excmpt under Scction-, B. & P.C. tirr this reason.
<br />I)ate:
<br />WORKERS' COI\IPENSATION
<br />DECLARATION
<br />I hcrcby atTirm untler Jrcnalty of pcrjury orrc of thc tirlkrwing tlcclaratiorts:
<br />_l havc and will maintah a Certificatc of Conscnt to Scll'-lnsurc tirr wrtrkcrs' comlrcnsation, as provirlcd tbr by Scction 37(U of thc
<br />labor Ctxlc. lilr thc Jrcrlirrmancc of thc work for which thc Jrcrmit is issuctl.
<br />(*:havc antl hy Scction .17fi) ol thc Lahor Cttdc, lirr thc grcrlirrmancc of
<br />carricr arxl Jxllicy numbcr arc:
<br />Policy | ?_,, 18.
<br />. _l ccrtify that itr the l*rlirrmncc of lhc work li)r which lhis pcrmit is issucd, I shall not cmploy any pcrson i[ any manncr
<br />sl as tr hecore subjel to lhc workcrs' comlxnsalion laws (rf Calilirmia, and agrcc lhal if I slkruld bccom subjcct to lhc
<br />workqs' coDpcnsuti(rn provisioDs ofScction 3?U) ofthc Lah[ Gxic, I shall, li)rthwith comply with tlf,,rc prcvisi(rns.
<br />WARNING: Failurc k) suc workcrs'comtrnsation covcragc is utrlawlul, and shall subjcc( an cmpkrycr k, criminal [EMllics.nd
<br />civil liucs up lo onc hutrdrcd thousmd dollus ($l0O,Ux)), in addili(rl k) lhc cos( ofcom[Ensation, d{mgcs as providcd for thc
<br />Scction .1076 of thc Lahrr Crxlc, irttcrcst and attorncy's
<br />I hcrcby allirnr untlcr Jrcnalty of pcrjury that I am liccnscd 9 (conrmcncing with Scction 7U)0) ol'Division -l
<br />of thc Busincss and Pnll'cssions Codc, and nry liccnsc is in lirll lilrcc and cllbct.
<br />Liccnse Gro Numhcr:
<br />W
<br />I hcrcby atfEm undq Fnalty of Ircrjury llut thsc is a constructirn lendinS agcrey for thc JErlirtmNc of thc work for which this Frmit is
<br />issucd (Scc. -1097, Civ. C.).
<br />[.ndcr's Namc:
<br />l,cndcr's Addrcss:
<br />APPLTCANT DECLARATION
<br />I trcrcby atlirm undcr pcnalty ot';rcrjury onc of thc lirllowing rlcclarations:
<br />Demolition Pcrmit.s-Asbcstos Notilication Federal Rcgulations (Titlc 40, Part6)
<br />-Rcquircd
<br />lrttcr of Notifrcation
<br />ccrli(y that thc t'cdcral rcgulalions rc-garding asbcslos rcnxrvalarc not applicablc to this projcct.
<br />cerlily that havc reatl this application with all City and County
<br />artd Statc l.aws rclatirtg and County Irt entcr ulx)n thc
<br />atxrvc mentioncr.l proJrcrty ftlr
<br />Applicant or Agent
<br />Pennitee natnc
<br />purFnscs.
<br />.f
<br />wrc, ll /4 .'Zo
<br />Flarr n9,-fi7 -)fi1 q
<br />insurancc, as
<br />work ttrr which this Jrcrnrit is wrlrkcrs'
<br />o*,, li.e t ,Z d
<br />,^r", ll.z+ 20
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