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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE !D/SIG.COMMENTS owNER ItUtl,t)ER t)Ul,( ARA',flON <br />Ihcrebyaflirrnunclerpenaltyofpe{urythatIenerernptfronrtheContractom l,icensel,awfirrthefolhwingreason(Sec.70,11.5 <br />[]usin6s and Profssion Code): Any City or County which requi|s a lurnit lo construcl. alltr, ilnprove, denolish or repair any <br />structure.priortoits issumce.alsorequirestheapplicantforsuchpenuitk)fileasignedstatenlenl thatheorsheislicorsed pursuanl <br />to lhc prcvisions ofthe Contractor's Licensed Larv (Chapter 9. Cornnrencing silh Scclion 7000 ofDivisioil 3 oftlre Business and <br />I'rcfessions Code) or that he or she i-s exempt lhq-elio,n and the basis lir the allcged exenrplion. Any violalion ofScction 701 1.5 by any <br />applicant frrr a pennit subjects the applicant to a civ il penalty o f not nu e than livc hu ndred dollars ( $500 ). <br />()f,/{lt r* <br />"rthe <br />pmpeny. or rny ernployees rvilh rvaga as their $le compeilsation. rvilldo the sork rurd rhe slftrctue is not <br />inlqrded orofTetedforsle(Sc-T044.BusinesandProfesionsCode:l'heConlractor'sl,icensel.awdosnolapplyloanorvnqof <br />lhe p(rpq1y rvho builcLs or improva lhqmn. md rvho doe such \\u{ hiiltsclIor lterselfor through his or her own ernpkrycs. <br />proridedlhalsuch inrprovqnentsilenoliiltrdedoroffsedfor$le.lf.ho\r'evs.thebuildingorirnprovernenlissoldrvilhinoneyw <br />ol coillplction. lhe L)\vner Buildq rvill have lhe burclm ofproving lhal he or shc did nol build or iruprovc the pftrpety for lhe purposeof <br />sle). <br />l. as o\\'nq ollhe propety. am exclusilely conlracling \r'ilh licolsed conlracloc lo conslnld lhe prciB*t (Sw. 7&14. tlusinss <br />and [tofesbn Code: The Conlractor's License Law dos nol apfly lo an o\ter ofpropcfl)r Nho huilds or improres lhereon. <br />and who contracls for such prcj(ls \\'ilh a Conhaclo(s) licenscd pursuant lo the (i]nlrachr's l-icflse l-aw). <br />I anr exenrln Strlion . ll .t I'y' lor thrs rcas*'Yr*,llWWffi <br />!2E(-!"!B ffQl <br />onc ofthc folkrr int rlcclarations' <br />(r",", <br />I hqeby amrm unde pmalty ofpojury <br />I have ard * ill maintain a Certificate of Conml lo Self-lnsurc for workqs' compfisation. m prorided for by Setion .1700 of the <br />t,atnr Codc. for the pqfonnmce ofthe $ork for rvhich the pennit is issued. <br />lhateandsillmaintainw'orkes compnsationinsurance.as requiredbySecti<rn1700ofthel-atxn(bde.forthepofonnanceof <br />thc rvork for rvhich this pmnit is issued. My *orkcs' compssalion insurance carier ad Jxrlicy rtrmbtr ile: <br />('arier: <br />rll-1,.,", :,. <br />[i\pires: <br />perlirnnance ofthe rvork for *hich this pctnrit is issuetl. I shall not mrplrrv anv pcrson in nnl nranncr <br />so askrlxconresubiecttothe$orko's'conryensnlionla\\so[(ali[omia.an(lrtrcrlhatiflshoul(llrconlcsuhicclk)thc <br />cilil l'ines up lo one hundred lhousan<l dollars ($100.(XD). iil addition lo lhc oI coDpcnsali()n. clanrages as proridccl frrr lhe <br />Sccltrn .1076 ofthe Labor Code. interest aild alknrv s fees. <br />t)t,t( t.ARA iloN <br />I hcrcby alfirm undcr poalty of perjury thal I arn licenscd undcr provist)n of( haplq () (cornnrencing rvilh Section <br />of lhc Business and Professions Code. mcl rny liccnsc is in full firrce and elTect. <br />l-iccnsc <br />l)&le: <br />l-iccnsc Nurrtlrr : <br />( onlrtclor' <br />CONS RU("I'ION LINDING ACEN('I' <br />I hereby aflirm unrlo penahy ofperjuq,lhat thqc is a conslnrclion lcnding agenc! for lhc pfrfonnance ofthe lrrrk for rrhich this psrrit is <br />issued (Se'. 1097. Civ. C.). <br />l-ends s Narne: <br />--I-encler's Addrss: <br />APPT,ICANI' DE('LARA-I'ION <br />I hadry allinn under pmalt;" of pejury one of the followiilS d(laralions: <br />Denrolilion Pqrnits-AsbBtos Notification Fedqal Regulalions (-l itle.l0. Pan6) <br />Req!ired Lelttr of Notificalion <br />I cdif),lhat the fedsal regulations regudirg astElos rernoval are not applicable k) this proi.{ <br />ild slate lhal lhe alxr|e infornralion is con'('t. I agre to cornply \r ith all City af,d ('ounty <br />ofthis ( ity anrl (irrrnt\ lo ealq' upoil the <br />alnve nrentioned propeny for <br />Applictrtrt or Agetr( <br />l'(rnrilcc ndillc (prinl): <br />construction.hercby authorize <br />-24-t7 <br />Set Backs <br />Forms/Steel/Holdowns IU ttQ ? Ap,t|6L *< <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf looriVenUl ns u lation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />l I ,l <br />FINAL 4 I r.{Va 7>tN vl/V 57 <br />Certificate of Occupancy rl <br />Notes, Remarks, Etc. <br />"yl-4-$-