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BUILDING. INSPECTOR RECORD <br />S!TE-WORK DATE ID/SIG.COMMENTS <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVl nsulation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />[Vlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />I <br />FINAL la l-(r Dl[,7 2/ <br />Certificate of Occupancy I <br />I <br />Notes, Remarks, Etc. <br />I <br />olvNl.R BrJil,t)l,ll{t{,\ | t( )\ <br />I hereby affirnr under penally of pcrjury that I m ercmpt from the Contrilcb6 Lic.nse Law for thc following reason (Sec.703 1.5 <br />llusincss ^nd Prolbssion Codc): Any Cily or Counly which requires a fDnnit h conslrucl, dller, irnprovc, dcrnolish or rcpair any <br />stnlcture. pri()r to its issuarrcc. also requires the applicaDt ti)r such permii b tile a sigrEd statcmenl that he or she is liccnsed pursuanl <br />to the'prrvisions of lhc Conlractor's l,icenscd ljw (Chaplcr 9, Cornmcncing wilh Scclion 7{Xn of Division 3 ol lhe Business and <br />Prolcs\r)trsCode)orthatheor\heiseremptlherefionrandthebasistbrtlEallc8ederenptiotr. Anyviolario[ofSectbnT03l.5byany <br />npplicinl for a pcrnit subjecls rhc npplicant to a civil penrlty of nor mre lhnil five hundrcd doltrrs ($5(x)). <br />_1. As owncr o I thc propcnv. or my t'rnployecs wilh wagcs as thcir solc compcn\!ti()n, will do (hc work and thc stnEturc is mt <br />itrtended or offered for snle (Se.7044, Business and Professions Code: The Conlractrr's Licensc I-ow does nol dpply b fln owncr of <br />the p()Itfly who buildi or imnrovcs llEr$iL urd who does such work himselfor lNrselior through his or her owil employees, <br />providcd that such improvcrrcnts trc mt intcnded or ollcrcd li)r salc. II. howevcr. th! truilding or improvcrrcnt is $ld within one year <br />ofconulcrirm. the Owner Buildcr will have the burden of p()ving thilt lE or she did nol build or imprcve the pmlEny for rlrc purlbse of <br />sxlc). <br />_1. as owner of the propeny. am cxclusively conlrncting wilh liccnsd conlraclors to con\trucl lhe prcjat (Scc. 7(x.1. Business <br />afil Pn,ll\sinrCode:TheContractor'sLicenseLawdrrrnotapplyrcanowneroflt()penywhobuildsorimprovesthereon. <br />and who conlracts for such projccts with a Contraclor(s) liccnsd pursumt lo lhc (\)ntrxctor's Liccnsc [aw). <br />I r[r c\.,rrln uDdcr B. & l'.C. Ii)r this rea\rrr. <br />"*ffi*I h('rcby rUirm under pcnall),of pcrjury onc of lhe lbllowing dcclaralions: <br />_lhaveandwill nraintainaCenificateofCoNenttoSelt:ln$raeforworkers'conrpcnsation,as providcdforbyScctionJT00ofthe <br />Gd*,*;ffi ffiffi***r**,**,iJffi:.,:*** ::le' <br />r'r'|he pcrr'"**e'r <br />t, <br />!7 lo \l''/i1r) <br />_lccililyrhrtinthcl^-rii)rn[nccolrheworkforwhichthispcrn]ilisissucd, lshrllnorcnrployrnyNrsoninrnynrrnncr <br />so is k) hcconrc subjcct o thc workcrs'conlpensalior lrw\ ol ('nlilornia. nnd rgrcc thnl il l should bccorrc suhjcct to thc <br />workers'conrPensarionpevi\r(,DsofScctionl?00ofthcl-ahtr(l(xle,lshrll,lbnhwithconrplywithtlDscprovisions. <br />WARNING: Failurc nr sccurc workcrs' c()nrpcnsiltion is unlawirl. rnri subjcct rn cnrpl()yer k) fininal pcmkics nnd <br />conrpensntiotr. damnges rs providcd for lhecivil lircs up to one hundred lhousand dollilrs (S in addir lhc <br />Secti()n 1076 ofthe Latxrr Crxlc. irlcrcst and <br />s i cr.:Sl)nl(:{qbzb - C"bL <br />I hdcby al lirm und!:r pcnalty ot pcrjury that I am Iic('nscd ol Chnpl(r 9 (corntncncing with Scction 70fi)) ol Division 3 <br />i)l thc llusincs\ and Prrrlcrsions Codc. aml n)y liccnrc is in lull fi)rcc rftl clllcl. <br />Ll*Nurnlrr:1 LlSS <br />,,'" { 't+'1cLc \I l,,t <br />(t <br />( ()NS',ilI'.( ilON LI,]Nt)t\(;.\(;t.:N( \ <br />I hcrchy allirnl under lttrahyofpcrjury that there is a conrtntction lcndiug agency lor lhe perfirrnrance ofthe <br />isrucrl (Scc. .1097, Civ. C.). <br />lf,ildcr's Nxnt. <br />li)r which this ts-flnil is <br />l.cn(lcr's Ad(lrcs\: <br />APPI,ICANT DECLARATIoN <br />I hcrchy rllim) undcr fEoalty of perjury one of the [olbwiDg (lrclirrti(tr]s: <br />Dcnbli(ir)n Pernrits-Asbestos Ndification Federal Regulations (Title.l0, Pan6) <br />-Requircd <br />lrller of Notifi calior <br />cef,ify that the federal reguhltnls rcguding asbesbs acn$vol are not applicable to this <br />I have rqd thi\ applicnlion ild stale lhat lhc nboye with nll Ciry and County <br />State Laws rclariilg k) buildiilg constructidl, uf,l herehy Cily ard County to enler uFrn tl! <br />trrnt()nd propef,y li)r' irlsnccli()n puqhscs. <br />or AgcDt (- <br />-fl'rnnil+c nanre <br />/kl A,\ <br />Rev. 08-07-201 5 <br />sh