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BU!LDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS oWNERBUILDERDELCARATION V <br />I hcrchy allirm undcr pcnalty ol pcrjury thilr I am cxcmpt lrrm thc Contrack)rs' [-iccnsc Law fi]r the ti)llowing rcason (Scc.7oll.i <br />Busincss and Prolcssi{)n Codc): Any City or County which requires a frcrmit to conslrucl, altcr, improvc, dcmolish or rcpuir any <br />structurc.prir)rk)ils issuancc.als()rcquircsthcnpplicantli)rsuchFrnlilk)fileasigncdstatcmnt lhalhcorshcislicensed Pursuanl. <br />b thc provisions ol'tlE Contract)r's Licenscd l-aw (Chaptcr 9. Comntcncing wilh Scction 7000 ot Division ,l of thc Bu\trtrs and <br />P()l'c$si(msCoJc)orthatheorshciscxemptth!-rcliomxndlhcbasislirrlheallcgcdc\cmption. AnyviolationolScclion?0-ll.5byany <br />appli(ant lilr a permit suhjccts lhc applicant k) a civil pcntlly of not nx)rc than fivc hundred dollars (S500) <br />_1. ns owncr of th!' p()[rcdy. or n1y empl()yccs wilh wJgcs rs thcir solc conrpcnsali()n. will do llE work drj lhc stnrcture is n{,1 <br />inlcndcd oroflcrcdlbrsalc(Scc.l044.BusincssandProltrsionsCnlc:lhcContracklr'sLicensel,!wdoesnotapplyhMowncrof <br />thcp[)[Eny whohuildsorinrprovcslhcrq)n.ilrdwhod(Essuchworkhimscll'orherscl[orthroughhis()rherowncmpbyccs, <br />providcd rhnt such improvcmnts trc ft)t intcftlcd or ollcrcd li)r srle. If. howcvcr. lhc huildilg or imprlvcmnl is v)kl within otlc )td <br />ot comphlion. lhc Owncr Buikler will have tlrc hurdcn ol provinS lhat lE or shc did not huild or imp(tvc lhc ptuFf,{y tbr lhc purF)sc ol <br />sah). <br />_1. rs owncr of thc propcny, rm cxchsivcly conlraelirS with liecnsed contractors k) conslrucl thc p()jccl (Scc. 7044. Busntcs\ <br />and l)tDli.ssirn(illc:'lhcConlrictor'sLiccnscl-awdot'sn(ildpnlytornowDcrol'prol{rlywh()huildsorimprovcslhcrcon. <br />and whr) contraclsli)rsuchpr)icctswilhaCo,ilraet)is)liccnscdprr\uantk)thc(:rtrilrxctor'sl-tccnsclrw). <br />_l nnr c\ctrrpl nrtrlcr Scct ll. & P.C. lbr thrs rcason. <br />IVO RK T]RS' COi\I PI]NSATIoN <br />I)ECLARATION <br />I hcrchy all irm undcr pcnalty ol pcrjury onc ol'lhc li)ll()wing dcclartli(usl <br />_lhavcandwill maintainaCc,tilicatcolConscnltlSclFlnsurcli)rworkcrs conlpcnsalion.as providcdli)rhyScction-17(X)ofthc <br />htx)r C(ilc, lbr lhc pcrtormancc ol thc work li,r which the pcrmit is i{sucd. <br />_l havc {nd will n[intain workcrs'conrpcnsali()n insuruncc. as hy <br />thc work ti)r which lhis is <br />Scct ion .17{X) of thc l-rh}r Codc. li)r lhc pcrli)rnuncc of <br />crfficr d]d F)licy numhcr trcl <br />i I 2-D zoPoliry <br />_l ccflily lha( in thc pcrlbrmrncc ol thc work l'(tr which thrs l--rnr( is issucd. I shall not cmploy nny pcrson rn nny nranncr <br />s() as k) hccomc suh.jcct k) lhc w(n'kcrs' c()nlpcnsation laws ol Crlifbrtria, rnd rgrcc thrl il I sh()uld hccomc suhjccl t) lhc <br />work!'r\'cr)mpcnsrtirrrpro!isi{)[\olSccti(r.]7{X)r)tlhcl.atxrrCrxlc.lshill.li)nhwilhcomplywilhlhoscp()visions. <br />IVARNIN(;| Failurr tr) sccurc workcrs'conrpcnsalion c()vcrigc is unlxwlul. and \hall suhjccl iD crnploycr lo cflminal Ftnxllics and <br />civil lint's up t) onc hutrilrcd thrNcand dollrrs (.$lm.Ux)). in addil(D to (hc of compcn\rtion. damnSes as providcd li)r the <br />Sccl()n C(trlc. trilcrcst rn(l <br />i ro <br />I hct!hy alljrm undcr pcnalty ol pcrjury that I am liccnsd undcr p()vision ol'Chaptcr 9 (commcncin8 with Scction 7U)0) of Division .l <br />ol' lhc Business and Prolcssions Codc. url my liccnse is itt lull lirrcc urd clltct. <br />l,iccnsc 'Nilrilhcr: <br />( <br />C]ONSTRUCTION LENDING AGENCY <br />I hcrchy aftirm undcr Fnalty of pcrjury that thcrc is a conslruclion lcnding agcncy fi)r thc Jrcrlbrmancc of thc work fi)r which lhis FErmit is <br />issucd (Scc. ,1097, Civ. C.). <br />[rndcr'r Namc: <br />I-cn(l.r'\ Arldf('\\: <br />APPLICANT DECI,ARATION <br />I lHrhy aliim undcr pcnalty ol pcrjury onc ol thc li)llowing dcclffationsi <br />Dcm)lit[)n Pcrnlils-Ashcsk)s Nolilicrtion Fedcral Reguhti0ns (Titlc 40. l'dn6) <br />_Rcqutrcd Lcltcr ()l Nolili.rlnnl <br />-l <br />c.rlily thrl lhc lcdcral rc!ulillions rcgiullitl[ ishcslos r('tiloval at(' rxil ilpPlicnhl(' lo lhis pft)jccl <br />| <br />-l <br />."nity rnar lhivc read lhis apnlrcation and slalc rhat thc {h)vc inlirrmali(}n is c()r.ct. I rgrcc lo (omply <br />I rcprcscnlatives ol lhi\ City <br />wilh !ll City and C(,unly <br />and C;()unly to cntcr !F)n thc()rdil)rn!c\ rnd Slrtc l-aws relating <br />ahovc orL'Dlirrrc(l l[opciy lbr <br />Applicanl or Ag€nt <br />Iterilrilee nrtrrr <br />rulhorizc <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 />Framing <br />lnsulation/Eneroy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />IMasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputv Final Report <br />Enqineer Final Report <br />Flood Zone Cerlif <br />/(\ <br />FINAL 7-7-7A kWlr\\ <br />Certificate of <br />Notes, Remarks, Etc <br />,.a-Lfro[ri-