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BU!LDING- !NSPECTOR RECORD <br />Rev. 08-07-201 5 <br />DATE ID/SIG COMMENTSSITE.WORK <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVl nsu lation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Enerqy <br />Drvwall <br />Ext./lnt. Lath <br />Brown Coat <br />Jvlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />FINAL <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />\rUl I lrJrztUt1,rt lA/\ <br />O\1'Nlllt lll rll,l)l,lll 't !()N <br />I hereby affirnr under penally of periury that I am exenrpt from llE ContracloN l-ictnse Law for the following resrcn (Scc.703 1.5 <br />llusincss and Prolcssiru Codc)r Any City or Counly which rcquires a pdrmit lo construcl, altcr. irnproye, dcmolish or repair any <br />slnlcture.priortoirs issurnce.aLsorequireslheilpplicaDlli)rsuchlErmilotileasi8Dcdslatemenl lhatheorshcisliccilsd pur$ant <br />to lh.' provisions ol the Conlrnctor's l-icenscd lrw (Chnflcr 9. CommcncinS wilh Scction 7fin ol Division 3 of lhe Business and <br />Prolcs\ionsCode)orthalhcorsheitexempttherelronlandtlEbxsisforthcallegcdexen:ptiur. AnyviolatiurofSectitrrT03l.5byany <br />ilpplicint for a peflnit subjects the npplicant to r civil pcinlty of nol mre lhrn fivc hundred dollars ($5(x)). <br />_1. as owncr ol-lhc prolEny. or my cmployccs with wagcs as lhcir solc compenslti(ih. will do the work 6rd lhc structure is mt <br />iiladed or offered for sle (S4.7(N4. Business and Professions Code: The Contrncktr s License Lsw docs nol apply lo an owncr of <br />thepR)pc(y whobuildsorinprovcslhere\ildwhdoessuchworkhimselforherselforlhroughhisorherowncnrployces, <br />providcd rhat such improvcrrnts uc mt iilended or olltrod for Mlc. 11. howcvcr, thc building or improverrcnt is sld wilhin one yee <br />ofconplcti(nr the Owrrr Buildcr will havc the burd.n ofpmving lld he or she rlirl u build or imprcve the pnrpcny for the purfDe of <br />slc). <br />_1, as owner ofthc pmpcny. dm cxclusivcly contraclinf with liccnwd conlraclon to construct the pmi:ct (Scc. 7{}14. Business <br />ood Pmtl$si[ Code: The Contracrrr's License Law does nd apply lo an owner of propeny who builds or improves thereon. <br />and who con[acts for such prdecls with a Contrachr(s) liccnscd pursuant to thc G)ntraclocs Licensc kw). <br />-l <br />am exempt undcr Sectiol-, B. & P.C. fbr lhis rea\oil. <br />l)cte:- <br />W{)RK I]RS' C0I\TPDNSATIoN <br />DIICLARATIoN <br />I hcr('hy allirm undcr penalty of pcrjulv onc of lhc tbllowing dcclarations: <br />_l have and will trEintairr a Cenilicatc of Consenr k) SclLlnsure for worlicrs' compeosation, as povidcd for hy Scction J700 of the <br />Latx)r Codc, for (he pcrformmc o[thc work tor which the pcrmit is issued. <br />,ZIGfri| n ui.ntain workers' compensation irsutunce, as rcquired by Section 3700 of the Labor Code, for the performncc of <br />thc w()rk tbr wfuch this pcroit is issucd- My workcrs' conrpnsation insurmcc canicr ul Jx)licy numbcr ile: <br />Policy L <br />_l ccIily thut in thc pcrtirrnuncc ofthc work tirr which this t)crnrit is issuc(|, I shilll not cnrploy ilny pcrson in any nranncr <br />so as () hccornc suhjcct o lhc workcrs'cornpcilsrlion llw\ ol'Cnlilbrilia. aDd a8rcc thrt il'l should hcco,re suhjcct to thc <br />workcrs'conrpensationp()vi\i(,nsofSectionl?00ofthr,l-ahrCode,lshll,linlhwithconrplywithtltosprovisions. <br />WARNING: Failurc o sccurc workcrs'conrlrcnsrtion covcragc is unlawful, rn(l shall subiccl an enrphryer k) qinlinul pcnalties rftl <br />civil lincs up to onc hundrcd lhousnild <br />Seclir)o 1076 ofthe Latx,r C(xle. intetest <br />doll.il s in addition to the corl oI cohp€nfi[ion. darogcs ns providcd for lha <br />and <br />o'L o dt (c <br />Itf,gtaurIgN <br />I hcrcby all'irm undcr pcnahy of pcrjury rhat I am liccnscd undcr povision ol Chnprcr 9 (cornmcncing with Scdion 70()) ol-Division 3 <br />ol thc Business and Pmtlssi()ns Codc. ffd nlv liccosc is in full t()rce md ellcct. <br />l-icc'nsc rogfottn 2'Lo'L' <br />CONSTRT]CTION T,I.]NDINC AGI.;NCY <br />I herehy altirm under lrnnlty of perjury that lhete is a conslntctirrr lerrdirlg xgency t(,r tlrc perfirmance of the work ,i)r which lhis pernlit i\ <br />issucrl {Scc. 109?. Civ. C.). <br />l-cr(lcas Nintr <br />la'nd('r's Arldress: <br />- <br />APPLICANT DECI,ARATIoN <br />I tEreby affmr under prnaky of perjury onc of the following declarations: <br />Denx,lition Permits-Asbeslos Notification Fecieral Rcgulatiorrs (Title 40, Pdn6) <br />_Requied ktter of Ndifi.ation <br />_l federill rcS0lxtiqls Egdding ashestrs renxrval are not apDlicrble k) this proiecl. <br />cenify that I luve reid thi\ applicat ion and stale that thc ahove infomation is corccl. I r8re to conrply <br />I represciltrtives ofthis City <br />with all Cily and County <br />and Couoly lo enter upon lhcorlirranecs and State Laws rchtilg t) hu construclifit aril heaehy authorizc <br />ahovc nrcnti()ncd prol-.*ny li)r <br />Appli(unt or Agcnt <br />/I'rrtrriler name <br />,or" 2- ?-o- LO <br />r '\\v <br /><:^,*,, \ 4Ce t4cr,'caa IrlS okaz cC C o