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BUILD!NG. INSPECTOR RECORD <br />S!TE.WORK DATE ID/SIG COMMENTS OWNI]R BTJILDER DI:I,CARATION <br />Busincss and Proltssion Culc): Any City or Counly which rcqukcs u Frrtril k) conslnrct. rltcr, improvc, dcmolish or rcpair an7 <br />stnrcturc.pri()rklits issuancc,als(,rcquircslhcappli(antti)rsuchfErnritlolilcasigncdslalcrrcnt thathcorsheisliccnscr.l pursurnf <br />to thc provisions ol rhc Contrack)r's Liccnscd ljw (Chaplcr 9. Commencing wilh Secti(,n ?0m of Division .l of lhc Busincss and, <br />ProlassionsC(xlc)orthatheorshcisctcmplthcrcliomandthcbasisli)rlhcnllcgcdcxempli()n. AnyvidationofScctxrnT0-ll.5byany <br />afplicantti)rapcrnritsuhjcetsthc applicrnltoacivilpcnrltyolnotmorcthanl'ivchundrcddoll$s(5500). <br />_1. as owncr ol lhc propeny, or my cmployccs with wagcs as tlrci solc conlpcnsation, willdo llrc work uld thc stnElfic is not <br />uilcndcd or()llcrcdlirrsalc(Scc.T044.BusincssandProlcssionsCorlc:'lhc(hlilractor'sLiecnscl,awdoesnolapplyt){nowncrol <br />thc pn)Fny who builds or improvcs lhcB)n. Md wh() d(Es such work hinlscll or hcrscllor lhnrugh his or hcr own cmployccs, <br />Fovidcd that such inrprovcmnls tm nol inlcndcd orollirc(l li)r slc. II. h)wcvcr. lhc builJing or inrpnrvcmnl is sold wilhin onc ycil <br />ol comphli)n. (hc Owncr BuiLlcr will hdvc tlrc budcn ol provurg lhat hc or shc did nil build or impR)ve the pmlEfly lilr thc puqD* of <br />snlc). <br />I. as owncr ol I hc p()J)cf,y. anr c\clu\rvcly contra(lir8 wilh Iiccnscd c(nilrack)rs lo c(rlslnrcl lhc projcct (Scc. 7(I44. Bu\flrcss <br />and P[rlcssirr(ixlc:'I'h!-Contrr(l()r'sl.iecnsc[-rwdocsnotxpplyloxn()wncrolprot--rlywhr]huilds()rinlprovcslhcrcon. <br />and wh() ronlrarl\ li)r such proiccls wrlh a Corlrackxl\) liccDscd pursunnl lo lhc Conlrark)r'\ l-iccnsc Lrw). <br />_l am crcnrpt undcr Scct i()n-, B. & P.C. lbr lhis rcason. <br />Orvner: <br />\\'( )tiKI,tRs' ( ol\tPI,.Ns,\.t't()N <br />t)t.t( L,1tt,\ il()N <br />l hcrchy al l irnr undcr pnalty ol ptr iury onc ol lhc lolk)wilw dcclaral i(n\: <br />lhaveiurlwillnuinrainaCciilicatcofconscnlk)Scll:lnsureli)rworkcF compcnsation,a\ pn)vidcdlbrhySecli([.l70Ooflhc <br />Lakrr Codc. firr t hc pcrlilmancc o[ th. work tbr which the pcrmit is issucd. <br />thc work li)r which lhis pcrmlt is issucd. My workers conrpcDsali()n irNurancc caricr md F)licy nunrhcr trc: <br />tPolicy <br />I ccnili thrt in rhc perlbrmrncc ol lhc wrrrk tilr which lhis pcrmil is issucd. I shall not cnrpkry any pcrson in any manncr <br />so as k) hcconr suhjccl to thc workcrs' conrpcnsat ion laws of Calilbmia, aDd aSrr'c I hal if I sh)uld hcconE suhjcet k) thc <br />workcrs'compcnlatir)npro!isi(DsolScction.lT0Oollhcl-at{)rC(xlc.lshall.l'onhwilhcomplywilhthorcprovisions. <br />IVARNING: fiailurc to scurc workcr\'compcnsrlion covcrlqc is unlawlil. antl shall subjcet an cmploycr k) canrilal lrcna[ics and <br />ctvil lincs up ((r rm hundrcd th{Nund dollars (Sl(X).(XX)), in ndditknr to lhc cosl ol'coDrNnsrtron. drmrScs d\ l()vidcd ti)r thc <br />Srct il ot (ixle. iolcrc\l tnd <br />I \o \ <br />DECLARATION <br />I hcrcby all-rrm undcr pcnalty of pcrjury that I am liccn$d undcr provision ol Chrplcr 9 (commncing with Scc(ion 7()U)) ol Divis()n .1 <br />ol the Busincss nnd Prolessions C(dc. ilil ilry liecnsc is iD till lbrcc ud cllcct. <br />l,icensc \Nunlbcri 9o qr lf <br />CONSTRUCTION LENDING AGENCY <br />I hcrchy atfirm unrlcr Jrcnalty of pcrjury lhat thcrc is a con\tnrclion lcndilg agency lor thc pcrlormancc of lhc work li)r which this lErmit is <br />issucd (Scc. .1097, Civ. C.). <br />lf,nJcr's Namc: <br />l,cnrlcr's Arldrcss: <br />APPI,ICANT DECLARATION <br />I hcrcby aflim undcr pennlty of pcr.iury onc of lhc li)llowing dcclaraliors: <br />Dcm)lilion Pcrnlits-Asbcslos N(ilificrtion Fcderal Rc8ulati{Ds (Tille 40, Pan6) <br />_Rcqutrcd [xltcr of Nolil'rcati()n <br />_l ccrlily thrt thc lcdcral retluliltioils rcguding rshcslos rcrnovalarc Dol xpplicublc k) thi\ prr.jccl. <br />_l ccnity thar I hxvc rcad lhis applicali(ilr iuxl slatc thdl thc ah)vc iDli)rnrali()n ir concct. I rgrcc lo cr)nrply wilh all Cily and Counly <br />ordmanccs afil Statc ljws rclatinp k)0f this City ard Counly to cnlcr uF)n lhc <br />itx)vc renlioncd proFny for <br />Applicanl 0r Ag(nl I I <br />It rnlitcc Damc <br />ukl ^%;;#""' <br />.() <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/Vent/l nsulation <br />Roof Sheathinq <br />Shear Wall <br />Framino <br />lnsulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />lMasonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />//1\ <br />FINAL 1-2*7 klw\t <br />Certificate of Occupancv <br />Notes, Remarks, Etc. <br />lhlo