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BUILDING- INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG COMMENTS <br />Set Backs ZN> Flsq- /1E!- <br />Forms/Steel/Holdowns ffi 6_2f.6 /zr-?) <br />Erection Pads \-Z <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenUlnsu lation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <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 />Enoineer Final Report <br />Flood Zone Certif <br />A-+ti-79F!NAL LL l9 Pe /?D:>*'2u'J <br />Certificate of Occupancv <br />Notes, Remarks, Etc.n <br />ft'r <br />./ <br />or<. tu <br />4-z <br />v lt <br />,c o <br />Z € <br />tc <br />( <br />c- <br />-6- <br />OWN I:R BUILI)I.]R I)tiLCARATI()N <br />I hcreby allirrr undcr pcnrlly of pcriury th{l I trnr cxctrrpt lionr thc Conlractu's' I"icensc [,aw li)r thc tolkrwing reason (9cc.7031.5 <br />Busincs\ rn(l Profcssi()n Codc): Any City or County which rcquircs a pcrnlit to conslrucl. altcr. intprovc. dcnr:lish or rcpair any <br />D .t*,.trr". prior to ls issurncc. il\o rcquircs lhc ilpplicrnl lor such Frnril lo filc a signed strtctrrnt lhal lt (I shc is liccnscd pursuanl - <br />/ tothcprrrvirirrnso,'thcCorlrnck)r'sLiccnscdLaw(Chxptcrg.CorrncncingwithScctiorT(XX)ofDivistr;n-lofthcBusincssantl' <br />l'roltssiolsC(xle)orlhlthcorshcisexctrptlhcrclronrrndlhehisislirrlhcallcgcdcxcirplion. Anyvkrtti(,nofS(tion7(].1l.5hyxny <br />npplicanllbrnpcnDilsubjcclslhe 0pplicrnlloacivilnctraltyofnoln()rcthnnl'ivchundrcddollrrs($5(X)) o <br />-1. <br />as owncr of thc prolEll y. or il1y cnrpkryccs w il h wagcs as thcir solc conrpcnsrtirrn. \'ill do tlrc work and llE stMlurc i\ un <br />iilcndfrl 0roflcrcdforsnlc(Scc.7(N,l.BusirrcssandProlcssionsC({lci'lheCofltrrck)r'sLiccnscl-ilwdocsnolxpplytoanowncrof <br />thc pn)pcrly who builds or inrl)roves thcrmn. and who (l(,cs such work hiillsclf or hcrsclfor through his or hcr own cmployccs. <br />providcdlhalsuch improvctrEnlstrcnolinlcndcdorolltrcdlbr$llc.ll.howcvcr.lhcbuildingorimprovcrmnlirsoldwithiD('ncvcitr <br />ol cotrrplcli(trr. lhc Owncr Buildcr will hatc Ih( burdcn ol proving lhnt hc or shc dil Dol huild or imprcrc lhc pnrFny lor lhe purfx)s of <br />srh). <br />_1. as owncr of lhc pn)pcrly, ilm cxclusivcly contracl ing wilh Iiccnsc(l contraclors t) conslrucl (hc projccl (Sec. 7(144. Busincss <br />and l'rrrft'ssirt Codc: Thc Conlraclor's l.iccnsc Law rlocs not aplly lo an owmr ol propcrty who huilds or inlpr)vcs lhcrcon. <br />and sln) conlracts li)r such projccl\ wilh a Conlraclo(\) liccnsc(l pursuxnl lo lhc Contrilctrr's Liccnsc [n!v]. <br />_l atrr cxcrnpl undcr Scctio[_ . It. & P.('. li)r this rclson <br />Dale:Owner: <br />1\'ORKERS' CoI\IPENSA'TI(IN <br />DECLARA'IION <br />lhcrchyilllirnrun(lcrpcnaltyolperjuryoncol'thcli)lk,iviilgdcchrxti(,ns: <br />-l <br />hurc or)d will DEinlrin r Ccnificrlc ol'Coilscnt k) SclLlnsurc lur workcrs conrlrcnsalion. ns providcd l'()r by Scction -17(x) of thc <br />litDr Codc. li)r thc pcrforiluncc oflhc work lbr which lhc pcrnrit is i\\ucd. <br />lhc wn'k liil' which lhis l)crnil i\ issuctl. My workcrs' conrPcnsation insurrncc crrricr nn(l policy runrhcr arc: <br />( <br />l\)licy ir cs: <br />-l <br />ccnit.y lhat in the perli)rmaocc of lhc work for which this lcrrlit i\ issucd. I shnll nol cnukry any pcrson in any nrilnncr <br />so ns k, lEco[rc suhjcct t) thc workcrs' coilrlrcnsal kxt laws of Califonr ia, nnd xgrcc I hat if I sh()uld hccorrc suhjcct to thc <br />workcrs' conrpcDsalion provisions oI Scction -]70O of thc l-atnr Corlc. I shrll, li)nhwith cotrlply wilh thosc prrvisions. <br />WARNIN(,: l;ailure kr sccurc workcrs'conrfcnsxli()D covcragc is unlawful. and shilll subjccl rn crnploycr lo crirninnl pcnillics a0d <br />civil lincs up lo onc hundrc(l lhousand dollars ($l(X).(Xn). in arldition lo lhc c{)sl o[compcnsalion. dxtrugcs as provi(lcd li)r lhe <br />Scction 3076 o, thc Lrtnr (ixlc. inlcrcsl nnd alhrNy s lL'cs. <br />I)ate: - Applicant: <br />LICENSED CONTRACTOR <br />DECLARATION <br />I hcrcby affirm undcr frcnahy of pcrjury that I am liccns{ undcr p()vision of Chnf,lcr 9 (comnrencing with Scction 7fi)0) of Division 3 <br />of thc Busincss and Profcssions Codc. and my liccnsc is in full li)rcc and cffcct. <br />I-iccnsc Cld\s:_Liccnsc Nunlbcr: <br />Drte: Conlraclor: <br />CONS'IRUCTION I I.:NDINC A(;I'NCY <br />lhcrcbyallirnrundcrptrnllyofpcrjurylhnl lhcreisacon\tructifilcndingagcncylirrthepcrfornunceoflhcworklbr*'hichlhirJnrmitis <br />Civ. C.). <br />Lcndcr's Arldrc\s: <br />)APPLICANT DECI.ARA'IION <br />I lrrchy allinr undcr pcnrlly of pcrjtx y onc of Ihe lirlkrwing dcclamtirrrs: <br />@mdition Pcrmits Asbcstos Notificalion Fcdcral Rcgulations (Tille 40. Pan6).Z <br />-Requircd <br />lrtlcr of Ndilicalion <br />_l ccnily lhat thc fcdcral rcgulations rcguding asbcsk)s rcmoval arc nol applicablc lo lhis pro.iccl. <br />-l <br />ccnify thlt I havc rcad;|is agpJication ud stalc lhal lhc ah)vc infonnntion is corccl. I agre to comply with all City and Counly <br />:ffJ#}ic|ff:ilffrfl#d,H'iiiH::lstruction. and hcrcbv authorizr rcprcscntarivcs orthis cirv nnd countvro cnrcr upon thc <br />2pplicanl <br />or Agent Signalure - _ <br />Permitee nome (prinl): <br />!-,W fu**f <br />l)atei