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BUILDING- INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS O}VNDR BUILI)ER DEI,CARATION <br />I hcrcby allirnr undcr pcnahy of Frjury lhal I am excmpl lntrn lhc G)nlrrck)s' Liccnsc hw l()r lhc lollowing rcason (Scc.70llL'! <br />Busincss {nd Pft)lcssion C'odc): Any City or County which rcquircs a lfrmil k, conslrucl. dllcr. improvc, dcmrlish or rcpilir {ny <br />structrrc. pri)r k) ils issuance, {lso rcqnircs thc applicant ti)r snch Frmil k) lilc n signcd slalcnrcnl lhal hc or shc is liccnsctl ptrsuanl <br />t(, Ihc p(rvisions of thc Contraclor's Liccnscd Law (Chaptcr 9. Cirnrnrcncing wilh Scction 7flX) of Division .l of lhc Busincss and <br />Pn)lcssi([sCod!')orthathcorshciscxcmptthcrcliomandthehrsisli]rthclllcgcdexenrptiur. Anyvi(]liltionofScclhnT0.ll.5hyany <br />ilpplicant li)r a pcrnrit suhjR-ls thc applicanl to r civil pcnahy ol not m)rc lhan flvc hundrcd dollars ($5fi1). <br />_l.as owncrol'thcpropcrty.ormyctnpl()yccswithwagcsaslhc'irsolccornpcnsalion.willtftllhework&ndthcslruclueisnol <br />intcrxlcd orofl'crc.dftrrsalc(Sc.r-.7()44.BusincssandProl'cssions(lilc:'l-hc-(irnlracl()r'sl.icenscLawtftrcsnotapplyloanowncrol' <br />thc pnrJrcfly whl huiltls ()r inlpr)vcs lhcrcon, and wlxr docs such work hinlscll'or hcrsclf or tltuluglt his rlr hcr own cnlployccs. <br />pnrvidcd that such impnlvcnrcnts arc m)t intcndcd or otl'crctl tirr sah. Il. howcvcr. thc huiklilrs or intprovcnrcnl is sokl within onc ycar <br />sah). <br />_1. asowncrol'thc property. atncxclusivclycontracting with liccnsctl conlractonloconstruct lhc project (Scc. 7()44. Btrsincss <br />and PnrlbssirtnCodc:'l'hcContractor'sl.iccnseLawdoesnotapplyloanowncrol'propcrtywhohuildsorimprtlvcslhcrcolt. <br />antl who contracls tilr such projccts with a Conlractor(s) liccnscrl pursuant to lhc'Conlractor's Liccnsc l-aw). <br />I am cxcnrnl undcr Scction . If . & P.C. lirr this rcastxt. <br />IVORKERS' CONI PENSATION <br />DECI,ARATION <br />I hcrr'hy all inn untlcr pcnalty ol'pcrfury onc ol'lhe lirlkrwirtg dcclaralions: <br />_l havc antl will maintain a Ccflilicatc of Consent to Scll-lnsurc'lirr wrlrkers'conrpcnsation. As providcd lirr hy Section 17fi) ot'thc <br />l-ahrr Crxlc. firr the Jrcrtilrnurrce ol the work tirr which thc prmit is issuerl. <br />_l havc will Sc'clion.17(X) ot'lhc I.ahor (irrlc, lor thc lrcrtitrttultcc'ol' <br />I ltt'carricr irnd grlicy nunthcr nrc: <br />€ <br />Policy <br />_l ccrtit'y that in thc pcrkrrrnancc ol thc work lirr which this J^-rnril is issuctl. I shall nol cnrpkry any pcrson in any nlatlncr <br />so as to lrcomc. suhjcct to thc workcrs' conrpcnsalion laws ot'Calitorrria. and asrcc lhat il' I shoultl hccomc subjcct ttt tltc <br />workcrs' comJrclrsation provisions of Scction J700 of'thc l-alxrr (iilc. I shall. Iirrthwith utntply with lhose provisiotts. <br />IVARNIN(l: Failurc to securc workcrs' conrlrcnsation covcrasc is unlawltrl. antl shall subjccl an ctnpkrycr to crintinal pcnaltics lurd <br />civil lrnc's up lo onc hundrcd tltrtusantl dollars ($l(n.(XX)). <br />Scction 1076 ol'thc I-alxlr Codc. irtlcrcsl and allorncy's li'cs. <br />ilr addition kl lhc cosl ot'c()mlrcnsalion.as providcd lirr lhc <br />,^*, b-L7 4q, <br />l .l('1..\.'s l..l ) ('( )N'l'R,\( "l o R <br />t)E('l,AR,\'l'loN <br />I hcrchy al'lirm undcr pcnalty of pcrjury that I arn lit:cnscd undcr provision of Chaplcr 9 (comnrcncing with Sc-ctkrn 70m) of Division J <br />of the Busincss and Prrlbssions Codc. and nty liccnsc is in tirll lirrcc ard cll'ecl. <br />[-icclrsc-Numlx'r: <br />o^*, (o-74Q t <br />CONSTRUC-TION LENDING AGENCY <br />I hcrchy allirm undcr Fnalty of Frjury that therc is . construclkrn bnding agcncy for thc lrcrlirrmane of lhc work tbr which lhis Frmit is <br />issucd (Scc. -1097, Civ. C.). <br />[rn,lcr's Namc' <br />lrndcr's Addrcss: <br />APPLICANT DECI,ARATION <br />I lrcr--hy allirm undcr pcnalty ol'pcrjury onc ol'thc tirlklwirrg dcclaratiotrs: <br />Dcnlrlition Pcrnrits-Ashcstos Notit'icatiorr Fcttcial Rcgulalions ('l'itlc 40, Part6) <br />_Rc'qu ircd I-cttcr rtt' Nolilicatkrrr <br />_l ccflily lhat thc tl'tlcralrcgulalions rcgartling ashcslos rcmoval trc not applicahle' to lhis pnrjc-cl. <br />_l ccnily that I havc. rcad this application urd slatc lhat lhc ahrvc' inlirrnraliott is crtmccl. I agrcc to conrply with all City and Counly <br />ordiltarrccs antl Slirlc [,aws rclaling lo huikling corrstrttclion. arrd hcrc'hy ivcs ot'this City attd County lo cnlcr trJxrn lltc <br />atxrvc nrcntionctl proJrcrly tor inspcction <br />Applicant or Agcnl <br />Irennilee nrnre (prinl <br />,or", (g -7 - (q <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bf loor/VenUl nsu lation <br />Roof Sheathinq <br />Shear Wall <br />Framing <br />lnsulation lEnergy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />[\Iasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />,.h, <br />FINAL 17-Y1-V0 .\{I)n <br />Certificate of <br />Notes, Remarks, Etc \./