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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG COMMENTS <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenUl nsu lation <br />Roof Sheathing <br />Shear Wall <br />Framing <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 2.zg-ueo J ).G,1,4v) <br />Certificate of Occupancy <br />Notes, Remarks, Etc <br />OWNER BUILDER DELCAR,ITIoN <br />IheebyaflirrnunderpenaltyofpcriurylhalImexemptliomlheContraclos LicmseLa\vforthelblkrwingreason(Sec.70-1t5 <br />IJusiness and I'r'ofessi<rr Codc): Any ('ity or Counly which requires a pmrit to conslruct, ahr. irnprove. donolish or repair any <br />slructurc,priortoils issuance,slsorequirestheapplicantforsuchpmnrttofileasignedslatonent thatheorsheislicensed pursuant <br />to lhe Fovisions oflhe Conlrackrr's [-icensed [,aw (Chaptq 9. Commencing with Seclion 7000 of Division 3 ofthe Business and <br />Professions Code) or lhat hc or shc is exempt lhqefrorn and the b6is for the alleged exenrption. Any violation ofSction 703 1.5 hy any <br />applicantfcrrapemritsuhjectsthe applicanltoacivilpenaltyofnotmorethanfivehundrcddollas($500). <br />l. as orvno oflhe poperly. or my employe6 rvilh rvags a their mle compensation. will do the work ild lhe structrtre is nol <br />intoded oroffoedforsle(56.7tX4.BusinesandPrefmionsCode:TheContractor'sl-icenselnwdo6ndapplyloanowntrof <br />the pmtuty rvho builds or irnFrcvs thqsn. md who do6 such rvort himself or hmelf or through his or hr own employcc. <br />proyided thal such i,nlrovqnenls ilc nol inloded or oflfrql for sle. If, hoNsq. the hrilding or irnpo|mot is mld $.ilhin one 1w <br />ofcornplaion. the Orvno Builds N ill have the burdm ofproving tha he or she did not boild or irngove the prcgaty for the purfnse of <br />sle). <br />I. as ou ncr ofthc ;ropmv, m erclusively conlracting s,ilh licflsed conlrad06 lo construct lhe proist (S&. 7O14. Busins <br />and [tofqsbnCode:'lheContractor'sLicenseLawdo6nolapplytodown6ofpropertvrvhobuildsorimprovGth6mn. <br />and who contracls for such projrcls wilh a Contraclo(s) licensed puBuanl to the Conlrador's Licose [arv). <br />-I ()nncr: <br />t)E( l,Atr\.iloN /4,LUE <br />I hereby a{firnt undcr pcnaltl oIpojurl one oIthe declaralions: <br />I have md $'ill n)aiilain fl ('erlillcale of lo Self-lnsure for workss'composation. as provided for by Smtion 3700 ofthe <br />the pamit is issued.Lahor ('odc. for lhc pofonnancc oflhe rvork <br />I have and rvill nraintain workers compensation insurance. as required by Section 3700 ofthe l-abor Code. [or the pq'fornance of <br />the work li)r which this pcrrnil is issucrl.works's compensalion <br />Policy <br />I ce(ify lhal in thc pcrlormance ofthe rvork for rvhich lhis pemit is <br />so as lo b€come subjecl lo lhe rvorkss' composation laws of Califomia. and agre that if I should hecome subjst lo lhc <br />\r'ork6s' compensation provisions ofSeclion .1700 ofthe Labo. Code. I shall. forthwith comply silh tho$ proYisions. <br />WARNING: failure lo sure workss'composalion covtrage is unla\,ful. and shall subjel an anployr lo qiminal pmahiG af,d <br />cilil fines up to thousand dollars addition to lhe cosl of compensat damagcs as provided for the <br />-t076 of Codq inlsGl ild attonrey's >)/7 <br />DI.:( I,AIL{I'ION /4,128 <br />I heeby allirm unde penalty ofperjury,ftat <br />of thc Busins and Profsions Codf, md <br />lan undo provision ofChapts 9 (comm6cing \vith S(lion 7000) ofDi\ision -r <br />is in full force od effet. <br />--,*tLicense C <br />/z- <br />>E/,3*c- <br />I herebv alfirnr rnclcr ltnally ol pq iury lhal lhdc is a lending agency lor lhe ps'trrnancc ol lhc lvork lbr uhich this 1urnil is <br />issued (Sec. 1097. Civ. C.). <br />Lender's Nsrne: <br />l,eids's AddrBs: <br />APPLICANT DECLAR{TION <br />I hotby affm undr pmalty ofperjury one of the following dalarations: <br />Demolition Psmils-Asb6tos Nolitjcalion Fedsal Regulations (Title 40. Part6) <br />_-Required [attr of Notification <br />-l <br />cstify lhal the fedsal rcgulations regdding dbeslos rmoval ae not applicable to this preject <br />_l c6tif) that I have read this application md slate lhat the above infonnation is cor(l aSre <br />ordinancs and Statc laws relatinS to and reprcsenlalils <br />above molioned propffy for <br />or Agent <br />l'crilrilcc nanrc <br />) <br />,,, <br />,*,"-l&loE/41 <br />7 <br />DrLre: / <br />l-/