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BUILDING. !NSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUII-DER I)ELCARATION r I <br />IhcrehyatlirmundcrpcnrltyofpcrjurythrtIamcxcmptlir)mlhcG)nlraclos LicenscLawforthclillk)win8rcason($c.70-11.5 <br />Busincss arxl Proltssi()n C(xlc): Any City ()r County which rcquircs a l--rmil to conslrucl. allcr. improvc. dcm()lish ()r rcpair nny <br />stntcturc. prior k) ils irsuancc, also rcquircs thc applicant lbr such Frmit lo lilc a siSned statcn*nt that hc or shc is liccn*d pursuanl <br />k) thc pr)visions ol'thc Contrack)r's Liccnscd Law (Chaptcr 9. Conrmcncittg with Scctt)n 7fiX) of Division -l of thc Busincss and <br />Prol'cssionsCodc)orthithcorshciscxcmptthcrchomandlhchasistirrthcallcgctlcxemplt)n. AnyviolationofScctitrnT0,ll.5byany <br />applicanltrrapermilsuhjcclsthe apphcantklacivilpcnaltyolnotnurclhnnfivchumlrcddollars(S5(x)). <br />_1, rs owncr of thc profEdy. or my emf byccs wilh wages as thcir s)lc compcnsali{)n. will d(} thc w(rk and tlr sltutm is nol <br />intcndcd orollcrcdli)rsalc(S(.7(X4,BusinessandPnrlcssionsC(rlciTheContract)r'sLiccnscLawd(tcsnotapplyk)anowf,crof <br />thcpn)frcrty whohuildsorimprovcslhcBrn.andwl&)d(rssuehworthimsclforhctsclfortltroughhisorhcrowncnrpl()yces, <br />Irrovidcd that such improvcnrnts m ftil intcndcd orollbrcd ti)r salc. ll, lx)wcvcr. thc buikling or inrprovcmnt is sold wilhin onc )cr <br />ofcomphtr)n. tlrc Owncr Buildcr will hdve thc hurdcn ol proving thal hc or shc Jid fril huil.l {)r impr(rvc thc pmlErty lor thc puqrcsc of <br />$lc). <br />_1, as owncr of thc prolEf,y, am exchsivcly conlracltrg with liccnscd c(nnrne krN k) conslruct thc proicct (Scc. 7044, Busillcss <br />anrl PnrlbssinCode:'IhcContract(,r's[-iccnscl-awdocstrotxpplyloanownerofprolrcrtywhohuildsorimProvcslhcrcon, <br />and who contracls li)r such projccls with i Conlrackn(s) liccnscd put'suant k) lhc Conlraclor's l-iccnsc Lnw). <br />_l amcxcmpt undcr Ii. & I).(. ftrr lhi\ rcr\r)n. <br />Dste :- <br />UABKEBS:COIIIENS4IAN <br />DECLARATTON <br />I hcrcby affirm undcr pcnalty of Frcrjury onc of thc li)llowing dcclaralions: <br />_lhavedi-lwill maiilailaCenificatcofConscntklSel[lnsurcti)rworkcrs comlcnsalion,as providcdlbrhyScctiul.]70Oofthc <br />tih)r Codc. for thc Frldrmancc of thc work for which thc pcmit is issuc,l. <br />_lhavcandwillmaintainworkcrs'comJrensaliorinsurancc,ls rcquirctlbySection-1700ofthcLihorCorlc.li)rthe[rcrlbmanccof <br />llrc work for which thls pcrmit is issucd. My workcrs conlpcnstti()n insurancc cafticr and fxllicy numhcr ilc: <br />Policy Number: Expircs: <br />_l ccf,ity that in lhc pcrli)rmancc of thc work li)r which this pcrmit is issuerl. I shall not cnrpkry any 1rcrson in any nllnlcr <br />so rs b hccorc suhjc'ct k) thc workcrs'c()mfEnsation hws ol Calilbrniil. and a8rcc lhat il I should hcconrc suhjcct b thc <br />workcr'compcnsationprovisi()nsofScclion-lTUlollhcL{tx)rCodc.lshall.li)rlhwitheomplywiththoscprovisions. <br />WARNIN(;: Ftihtrc k) sccurc workcrs'compcnsali{)n covcragc is unlawlitl, and shtll subjcct an cmpk}ycr lo crimintl fEnaltEs nnd <br />civil tlncs up t) onc hundrcd thousand d()llars ($lu),ftD), in arldition lo Ihc cosl ol compcnsati()n, drnugcs as provilcd tilr lhe <br />Scction -1076 of thc [-ak)r Culc. iilcrcsl and altn'ncy s tccs. <br />,\pllit ant: <br />LICI'NS!]D CONTR,\CToR <br />I)ECLARATION <br />I hcrcby allirm undcr pcnrlty ol pcrjury that I anr lircnscd undcr p(x isiiD ol Chrplcr 9 (conrnEilcint with Scction 7Un) of Divis(i .1 <br />ol' lhc Busincss and ['rolessrrns Corlc. iurtl nty liccnsc is n tull fi)rcc aild cllccl. <br />Liccnsc Ctass:-Li(cnsc Numltr: <br />W <br />I herchy atfirm undcr fEnalty of pcrjury that thcrc is a conslructirn lending agcncy lbr lhe pcrfbrmnce of lhc work tbr which lhis fErmit is <br />issucd (Scc. 1097, Civ. C.). <br />kn.lcr's Namc: <br />hndcr's Arldrcss: <br />APPLICANT DECLARATION <br />I lrcrthyallimrundcr pcnally oIpcrjury onc ol the lblk)wing dcelarations: <br />DcnDlilion P.rmils-Asheslos Notilicatirtn Fcdcral Rcgulttions ( l illc 40, Pffl(, <br />-Rcquircd <br />latlcr of Notilication <br />_l ccrtily (hrl thc tcdcral reSulatir)ns rc8trdrng l{bcslos rclnoval arc nol {ppllc{l}lc k) this projcct. <br />_l c(rtili lhnl I luve rcad this applicatt)n md statc that lhc ahlvc hlornulir)n is cotrccl. I aElre b cr)mply with all City and County <br />ordutance$ and Statc liwr rclating b huilding constructt)n. ild hcrchy aulhoriz-c rcprcscnlatives (!f this City md Counly lo cntcr uf(D thc <br />ala)vc mntiurcd pft)pcdy li)r inrpcction purFx)scs. <br />Applicant 0r Agcnt <br />I'oruitor nniltr'l <br />l)ale:_ <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenVl nsu lation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulationi 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 />{, r/ <br />FINAL rt'tt'' lc'll U)fut"/i,Y o <br />Certificate of Occupancy <br />Etc. <br />( irnlracft)r: