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BUILDING- INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUTLDER DELCARATION <br />I hcreby rlltrm undcr Fnalty of Frjury lhal I am cxcmpt hom lhc ConlracmN' Liccns Law litr lhc titlkrwhg rca$n (ScfiOJl.s <br />Busincss afil Profcssion Cirxlc): Atry City or County which rcquircs a [rcrmit to construc(. altcr. imprcvc. dcmolish or rcIBi, any <br />slructurc, prior to its issuancc, als(' rcquircs thc applicunt for such lEmil kr tilc a sigrcd statcmnt thal hc or shc is liccn$d Pursuani <br />to thc Jnrvisions of thc Contrackrr's Liccnrcd law (Chaptcr 9, Comnrcncing wilh Setbn 7000 of Division -l of thc Busircss and <br />PrufcssionsCodc)orthathcorshciscxcmptthdclnrmandthchasislbrthcalhgcdcxcmption. Anyviolationofsccti(D703l.5byany <br />applicant lbr a F mil subjels lhc applicanl to a civil pcnalty of trr)t morc th{n f ivc huilrcd dollars (5500). <br />_1, as owncr of the propcrty, or my cmployccs with wagcs as lheir solc compcnsalion, will do thc work atxl thc strur,*turc is nol <br />iltcnded orofl'crcd ftlr .sale (Scr-.7044. Busincss and Pnrfbssions CrxJc: Thc Contractor's Liccnsc [-aw drrcs ntlt apply to an owner of <br />thc propcrty who builds or impn)vcs thcrcon, and who d<rcs such work hintsclf or hcrself or thn)ugh his ttr her own cmployccs, <br />pnrvidcd that such improvcrncnts iuc not intcrdcd orollcrcd lilr salc. It, howcvcr, thc buikling or improvclncnt is sold withrn otlc ycar <br />ol'complction, thc Owncr tsuiLJer will have the burdcn ol'proving that hc or shc did not buill or improvc the pnrpcrty lbr thc purprsc of <br />salc). <br />_1. as ()wncr o[ the proJrcrty, am cxclusivcly contracting with liccnscd contractors to construct thc pro.iect (Scc. 7U4, Busiucss <br />and PnllbsskrnCotle:ThcContractrlr'sl-iccnscl-awdocsnotapplytoanowncrofprrtpcrtywhohuildstlrimprovcsthcreon. <br />and who contracls lirr such pro.iccts with a Contractor(s) liccnscd pursuant to thc Crtntractor's Liccnsc Law). <br />-l <br />am cxcmpl undcr Scction-, B. & P.C. for this rcas<ltt. <br />ll.,r^. <br />UOETEESSOMPINSAIIqN <br />DEC!.A8AIIAN <br />I hcrchy altirm undcr pcnaltyofJsjury ouc ofthe folhwinS deldalions: <br />_lhavcandwillmintainaCcnificatcofc(rnsnttoSclFlnsurcforworkss'compcnsalion,as prcvidqllorbySetiltn.lTfi)ofthc <br />Labor C(xlc, for tlE Frfirrmncc of lhc qrrt lbr shich thc Frmit is issucd. <br />all havc rnrl will mointain workc6' comlrcnsation insurancc, 8s requircd by Scct ion .1700 of thc tihor Codc, tbr thc 1Ertitrmret of <br />thc work for which this Frmil is issql. My workqs' smlrcnsalion insurancc cuier anl F)licy numbcr ec: <br />SA#e- FrnJ <br />poricy N"r',h"r, ?O 3 Oq 3 tr Expircs: .//- /-AL / <br />_l ccrtily lhat in thc pcrlirrmancc of thc wrlrk tirr which this Jrcrrnit is issucd, I shall not cntpkry any frcrson in any matlncr <br />so as to bccomc suhjcct to thc workcrs'comJrcnsation laws of Calitilrnia, and agrcc that if I should bcctlmc sub.icct to thc <br />workcrs' comJrcnsation provisions ot'scction 3700 of thc l-ahrr CrxJc, I shall, tilrthwith comply with thosc provisions. <br />WARNING: f;ailurc to sccurc workcrs' comJrcnsation c()vcragc is unlawt'ul, and shall subjcct an cmploycr to criminal Jrcnaltics and <br />eivil lincs up to onc hundrcd thousand dollars (S100,Uru), in adrlition to thc cost of comlrcnsation, damagcs as providcd tirr thc <br />Scction 3076 of thc l:txlr Ctxlc, intcrcst and atlorncy's l'ccs.4"COLO Annlicnnt: K <br />LI <br />DECLAR/ITION <br />I am licenscd under provision of Chaptcr 9 (commcncing with Scction 7firu) of Divisitln 3 <br />my liccnsc is in tbll tirrcc anrJ ctI'cct. <br />I hcrcby allirrn undcr pcnalty ol'pcrjury lhat <br />ol' thc Busincss anrl Prcl'cssiorts Codc. arx,l <br />Licensc ,r^rr, C39 Liccnsc <br />tc/F26r <br />2ec Pz-o <br />W <br />I hcrcby allirm unrlcr Jrcnalty of Jrrjury that thsc is a coNtruclirn lcnding aSency tbr lhc Jrcrfirrmancc of lhc wtlrk hlr which thi\ JEmit is <br />issued (Se. -1097, Civ. C.). <br />lrnder's Namc: <br />APPLICANT DECLARATION <br />I hcrehy allirm untlcr pcnalty ol'Jrcrjury onc of thc lbllowing dcclaratiotts: <br />Dcmolition Permits-Asbcstos Notification Federal Regulations ('l'itlc 40, Part6) <br />-Requircd <br />lrttcr of Notitication <br />_l ccrtily that thc l'cdcralrcgulations regartling asbcstos rcn'xrvalarc not applicablc to this pr<tjcct. <br />_l ccrrily that I havc rcad this application and statc that thc alxrve intilrmatiotr is corrcct. I agrcc to comply with all City and County <br />ordinanccs and State l.aws rclating to building hcrcby authrlrizc rcprcscntatives of this City anrl County to entcr uJxln the <br />atxrvc nrcntioncd pro;rcrty lirr <br />Applicant or Agcnt <br />Penrritec nanre <br />,r^r" €e. Q zozo <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bf loor/VenUI rtsu Iatio n // <br />Roof Sheathino{r l7lrflrV frhlbDK,V <br />Shear Wall I <br />Framinq <br />lnsulation lEnerqy <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 />-ttl J\I //3 <br />FINAL Itlt\ll]11,r0 t <br />Certificate of Occupancv I <br />Notes, Remarkq, Etc.I I ^ ,tt.^ro <br />rl <br />Rarr fiA-n7 -2n 1 q <br />I <br />I <br />uraiil,lM <br />d)mrtn <br />I <br />I <br />l\--a...