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BU!LDING. INSPECTOR RECORD <br />SITE.WORK DATE !D/SIG.COMMENTS OWNER BI.]II,DER DEI,CARATION <br />I hcrchy allirm undcr lrndlty of l^-rjury thrt I anl cxcmpt lil)nr thc C(,nlrncbrs Liccnsc L{w li)r lhc li)lk)wirg rcason (Scr.70-}1.5 <br />Ilusilcss anil Proltssion C(xlc): Any City or County which rcquircs a lrcmil k) conslrucl. nltcr. rmprovc, dcnr)lish or rcpair any <br />slructurc.pr$rk)ils issuancc.nlsorcquucrlhcapplicanlli)rsuch[rcrnliltrlilcasigncdstatcntnt lhalhcorshcisliccnscJ Pursuanl <br />t) thc provisions of thc Contrack)r's Liet'nscd llw (Chaplcr 9. Commcncirrg with Scction ?Ux) ot lrivi\i(]n .] ol lhc Busincss and <br />ProlissionsCode)orthallrorshciscxcmptthcrcliomindthchasislorlhcallcgcdc\cmption. AnyviohlionolScclionT0.ll.5hyany <br />apflicrnlli)rat^-^rmitsubjeclslhc applcrnlloacivillcnrllyoln(ilnn)rclhanfivchundrcddolldrs(S5U)). <br />_1. as owncr ol'thc pr)[E(y. or my c mlk]yccs wil h waScs {s I hcir solc compcnsrlion. will d() thc work uxl lhc stnNlurc iJ not <br />intcndcd orotlcrcdlorsalc(Scc-T044.BusincssudPn,lission\Codc:ThcConlrack)r'sLiccnsc[-awd(]csnotapplyl)anowncrof <br />thcpn)lf,(y wk)huilds()rimprovcrthcBln.iurdwhod(rcssuchwo*himsclf()rhcrsclforthroughhisorhcrownempk)yccs. <br />provided that such improvemnts dc not intcndcd (,rolllE{ li)r salc. Il, h()wcver. thc huihling or irnpn^cmnt is sold within onc yeitr <br />ofcomplct(D. thc Owncr Buildcr will havc thc burrlcn ol proving that lrc or shc did ret buill or imp()vc lhc pfi)FLffy lirr llE puryr)* of <br />sab ). <br />l. as owncr of thc prcpcfty. nnl cxclusivcly c()trtrr(tilrg willl Iiccn\crl contrack)rs t) conslnral lhc pi)jcel (Scc. 7(I,14. Ilustrrcss <br />tnd who conlrrcts li)r such projccls wilh a Ci)rilrnclor'(\) licctrscd pursuxnt k) thc Contractor's l-iccnsc l-ilw). <br />-IrnrcxcmPlundcrsccti(u-.l]'&P'C.Ii)rthisrcason, <br />TVORKERS' COI\IPENSATION <br />t)ECl-ARATION <br />I hcrchv nllirm un.l!'r l^-nrlly ol FIjury onc ol lhc k)llowin! (lcchralx)ns: <br />_l havc erl will mainlain a Cenillcalc ol Conscnt k) Scll:lnsurc li)r workcrs' comlEnsation, as pn)vidcd li,r by Scctmn -1700 ol lhc <br />htx)r C(xlc. lbr thc lErli)mrancc ol lhc work lbr which lhc fErmil is i\sucd. <br />_l havc and will maintain workcrs compcnsali(nr insurancc. as rcquircd hy Scclion -1700 ollhc tlh(,r G)dc, li)r thc pcrli)rnlancc o[ <br />thc work lbr which this permit is issucd. My workcrs corllxnsati(,n insrrancc cuier erl F)licy nunlhcr dc: <br />Pohey Numhcr: Erpircs: <br />_l ccdity lhtt in thc pcrli)rnililcc r)l lhc work in'whrch lhrs pcrnrit is is\ucd. I shill nol cnrfk)y xny fcr\ln ilr rny mirlncr <br />workcr\'coirplJrsalirfiprovis()nsr)lScction.lT00olthcl,rlx)rCrx,c.lshall.linthwilhcomplywilhthoscnn)visi(nrs. <br />crvil IiDcs up l()huntlrcd lhrrrcarrl dolhr\ ($l{)0.01x)). ir lo cosl ol- corlpensrli(rl.lbr lhc <br />Srclxnr 1076 ol irilcrcsl rild rtkrrncy \ lics. <br />I hcrchy undcr Frmlty ol pcrjrrry lhal I rnr ol Chaptcr 9 (eonrnrsrcinS with Scct()n 7(XX)) ol t)iviriu -l <br />ol' thc Busincss and Pn)ttssi()ns Codc. md my is in l'()rcc url cffcct. <br />[,iccnsc 3. <br />I herchy alltm undcr [Enally ol pcrjury thal lherc lcnding agcncy tor thc pcrli)rnrancc ol lhc wr)rk li)r which lhis t--rmit is <br />issucd 1Scc. -1097. Civ. C.). <br />Lcndcr's Namc: <br />l-endcr's Adrlrcss: <br />APPl,ICANT DECLARATION <br />I ltNby rllirm under Jrcnrlty ol pcrjury rnc ol I hc l;l[)wint dcelinl (rs: <br />[)cnx)lition Permits-Asbcstos Nolilicnlron Fcdcral Rt!ulalioDs (1 ilIc 40. Pan6) <br />Rcquircd hltcr of Notil'icrliur <br />_l ccniti lhat the fcdcralrceulations rc8ilding ashcsk)s rcmovlltrc not applicablc lo lhis proFct. <br />_l ccnily lhat I htve rcad lhis application and slarc thal thc rtx)vc inlomation is corect. I agre h c{)mply wilh all Cily and Counly <br />ordiranccs ild Statc Laws rclaling k)()l this Cily rnd <br />rhovc nEntioncd properly li)r <br />Applic{nt 'rr Ag€nt <br />I'crtrrilcc nanrc <br />inrl hcrcby rutl$rizc <br />Als <br />lo cnlcr uF)n lhc <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 />Framino <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 />FINAL b/f.?Pr,o Jr'e{th -Yd <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />L-