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BU!LDING. INSPECTOR RECORD <br />SITE.WORK DATE !D/S!G 'COMMENTS OWNER BUILDIiR DEI,CARA'TIoN II hcrcby aft'irtrr undcr pcnxlty ol pcrjury that I arn cxcrnpl lron! lhc (i)nlract)rs Liccnsc Law for thc l'()lk)wing rcn{(tn (Scc.7{ll/5 <br />Busincss nnd Proltssi(t Codc): Any Cily or County which rcquircs n pcrnlil l() construct. rlter. imJrrovc. rlcnrrlish or rcp:rir {ry <br />slruclurc.prk)rloils issuancc.alsorcquircstheappticantforsuchltrnlitk)lllcil\igncdslatcrmnt lhalhc()rshcisliccnrcrl pursu\t <br />lo lhc provisbns of llE Conlrrclor's Liccnscd Law (Chuplcr 9. Comnrcncing silh Scclion 7Un of Division J of thc Busircsr ar& <br />ProlessionsCodc)orthalhcorshciscxcnrptlhcrcftomandthchosislirrthcallcgcdcxcmption. AnyviolalionolSccttrnT03l.5byany <br />applicctrlforapcrmilsuhjccl\lhc applicnnlloncivilpcncltyofnoltrr)rcthtnlivchundrcddollars($5fi)) <br />_1. as orvncr of lhc l)r()[rcny. or rny cmnk)yccs wilh wn8cs ns lhcir solc comPcnsation. \'illdo lhe work atxl llrc (tnElurc is nol <br />iilcndcd oroffcrcdli)rslc(Sc-".T(}44.RusincssandhofcssionsCodcifhcContrilck)r'sLiccnscIjwdocsnotnpplykrnnowncrol <br />lhcpmFny whobuildrorimptr)vcslhcrqrl.Mdwhod(rcssuchworkhimrcl[orhcrsclforthroughhisorhcrowncnuk,ycc{. <br />providcdthatsuch improlrntnlsilrcnolinlcndcdoroflcRalkrrsalc.lf.hrrvcrcr.thehuildingorinprovcrrcntisy)ldwithiil(ntcJrir <br />ofcomphli()n. lIrc Owncr Buildcr * ill havc lhc hurden ofproving lhat hc or shc tlirl not hnikl or imrrcvc thc pmfrny li)r lhc purlxrsc of <br />t4 Pmfijssirr Codc: 'l hc Conlrrclor's l,iccnsc l,dw docs nol apl)ly to rn (,wncl'ol pr()pcrty uho huilds or inrprrvcs thcrcrrn. <br />ilnd wh() (onlrilclslirrsuchprrjcctswithaC'orilmclor(s)licl'Isc(ll)ur\lhrnl()lhc(i)nlrilcl(nisl-iccnscLnw). <br />_l nN cxcnrpl undcr Sccl & r,.(-. rbr <br />Po,,"' { , [[ -t1 X-,".[6( <br />DECI ARATTON <br />I hereby aflirrn undcr pcnalty of pcrjury onc ofthc following declaralions: <br />/ have :uxJ will nuirlain a Ccnificute ofConscnl lo Sclf-lnsurc for workcrs cornfcnsalion. as providcd for hy Scction .17{x) ofthc <br />Lrbor Codc. for thc pcrfornumcc of lhc work for which thc pcrmit is issucd. <br />-lhavcandwillnlrinlrinw()rkcrs'conrpcnsrlioninsurance.as <br />rcquirctlhyScction3T(X)oflhcLahorCodc.fi)rthcpcrli)rnlilnccof <br />thc work li)r which thi\ pcnnil i( is\ucd. My workers conycn\xlion insrrlncc caricr anrl lmlicy numhcr:rc: <br />Policy Numhcr: llxnircs: <br />-l <br />ccrtify lhal in thc ltrlirrmancc of thc work for which lhis pernlit is issucd. I shtrll nol cnlploy any person in any rranncr <br />so as lo bcconr suhjccl lo lhc u'orkcrs' conrpcnsalion laws of Calili)mit. rnd ilgrcc lhat if I should hecom subjcct b thc <br />workers'conrpcnsrli(ilprovisionsofScclionST0Oofthetntx)rCotlc.lshall.fonhwithconrplywiththosp()vist)ns. <br />WARNING: Failurc lo scurc workcrs'conrpcnsilhn covcragc is unldwlul. and shall subjccl an cillploycr to rrinlin{l lrnilltics tnd <br />civil fincs up lo onc hundrcd thousand dolLus (Sltn.0fi)). ir ilddit <br />p <br />lo lhc cost (,f compclsiltion. danugcs as providcd for lhc <br />Scction 1076 ol lhc Lrh)r (ixlc. irilcrcsl rnd attorrcy s <br />)o*", <br />{-1,UilX 'a.hl.-,l <br />of thc Busincss and Prrrltssir:ns Codc. and nry Iiccnsc is in lill li)rcc and cllcct. <br />Liccnsc Class:_l,iccnsc Nuillhr: _ <br />Date: _._-_ Contrsclor: <br />CONSTRUCTI(IN LENDIN(; A(;ENCY <br />I hcrcby affirm u[dcr fEnally of Frjury lhal lhcre is a construction lcnding agcncy for lhc pcrformancc of thc work for which this Jrcrmit is <br />issucd (Scc. .1097. Civ. C. ). <br />Lcndcr's Nrnrc: <br />lxndcr's Addrcss: <br />APPLICANT DECLAIl1\'TION <br />I hmhy atlirnr undcr pcnrlty of pcrjury onc of lhc following dcclarilt ions: <br />DcmolitioI Pcrnlils-Ashcslos Nolilicnlion Federal Rcgulations ('l'illc 40. l,rrl6) <br />-Rcquircd <br />Lcltcr ol N(f ilicali(trr <br />\ rcSrrdiilg ashcslos rc'trx)vil ilc nr{ applicrhlc k, (his lrojcct. <br />i{)n and \lnlc lhrl thc rlxrrr- inkrrrrlion i\ c()rcct- I rgre lo comnly with all Cily rnd County <br />r rcprcscnlativcs ofthis City ancl County to cntcr uF)n llrcconstruclion. and hcrchy auth()rizc <br />Applicant or Agent f - | {,r-l( <br />Pemrilee ntrne ct I <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 />IMasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />I I <br />F!NAL lo g 4d \>fiwY 7 <br />Certificate of Occupancy 7 <br />Notes, Remarks , Etc