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BU!LDING. INSPECTOR RECORD <br />SITE.WORK DATE !D/SIG.COMMENTS OWNER BUILI)ER I)ELCARATION <br />I ht'rchy allirnr unJcr pcnalty of pcrjury that I am crcmpl liom lhc Conh'ack)rs' Liccnsc Law ti)r the lbll()wing rcason (Scc.7031.5 <br />Busiltcss and Proli'ssion C(xlc): Any City or County which rcq[ircs n Jrcrnrit k) construcl, allcr. improvc. demolish or rcpxir dny <br />struclurc. pri)r to its issuanrc, alsi) rcqrircs the afplicanl tbr such fLrmil lr tilc a signcd stalcmnt lhat lr or shc is liccnsd pursuanl <br />m thc provisions ol'thc Contractor's Liccnscd Law (Chaftcr 9, Ci)mmcncing with Scclion 70(X) ol Division -l of lhc Busincss nnd <br />Protcssi()nsCodc)orrhrthcorshciscxcmpttherctromrndlhcbasislilrthcallcgcdcrcmpli(m. Anyviolationo[Scclion70.]l.5hyany <br />rplliranlli)rapcrmilsubjcclslhc apfrlicanlk)!civilpcnrllyoltrotnxil'cthanfilchundrcdrlollus(S5il1). <br />_1. ts owncr ol'thc proFrc(y, or my cmpl()yccs with wagcs as thcir solc compcnsati()n. willdo thc work erd thc slruttrc is nol <br />intcndcd rrroll'ercdli)rsalc(Scc.?044,BusincssandPfl)ftssionsCodc:TheContrack)r'sLiccnsel-awdocsnotapplyk)anowncrof <br />thc pr)lErty who huilds or inrprovcs lhcB)n, md who d(rcs such work himsclfor hcrsclfor lhrough hls or hcr own cmpk)yccs, <br />providcd thal such improvcmnls m not intcndcd orotlcrcd li)r sak. If. h()wcvcr.lhc huilding or impRlvcmnt is soll wilhm onc ycil <br />rll eomplction. lhc Owncr Buildcr will havc thc hurdcn ol pr)vi,rg that hc or shc dd n()t buikl or improvc lhc pruIEf,y lor lhe lurytr of <br />salc). <br />_1. as owncr ol th(. p()fcrty, am cxchsivcly conlractirtg wilh Iiccnscd c(rllrack)rs k) conslruct lhc Fn)jcct (Scc. 7044. Busmcss <br />an(l lh)lbssidlCodc:l'hcContrdctor'sl,iccnse[-awdocsnolapplytoanowncrofprolcrtywhohuildsorimproveslhcrcon. <br />and who conlrrcts lilr such pn)jccts wilh a Cilntrrck)(s) licoiscd fursu{nl k} lhe Contracl()r's Liccnsc Law). <br />_l rnr c\cnrpl unllcr'l). & l'.(. li)r lhrs rcx\or. <br />Iht(.:- <br />lYORKERS' CONIPENSATTON <br />DECLARATION <br />I hcrcby all'irm undcr penally ol t^:rjury onc ol thc Ii)llowing dcelaralions: <br />_l hdve and will maintain a Cciilicatc of C(,nscnt k) SclFlnsurc lbr workcrs' compcnsation. as lrovidcd lirr hy Scction .1700 of the <br />L{tx)r Codc. lbr thc pcrf(}muncc o[the work ,br which lhc pcrnrit is issucd. <br />_l havc an,l wrll maintril workcrs compcnsrlion insurancc, ns rcquircd hy Scction -l7U) ofthc t-ah)r Codc. fi)r thc pcrlbmlancc of <br />thc work li)r which this pcrmil is issucd. My workers' compcnsalion insurancc canicr and Jnlicy numhcr ucr <br />c, <br />Policy u loLlaq" <br />I <br />_l ccrtily tlul ir thc pcrli)rnrancc of thc work li)r which lhis pcrlril is issue(i. I shxll nol cmploy any pcrson in any manncr <br />so as kr hccomc subjcct k) thc workcrs'c()nlpcnsalt)n laws ol Crlili)rnia, and ntrcc lhnt if I slxruld hcconrc suhjccl lo thc <br />workcrs'conrpcnsrti(nprovisi(ilrsolSccti(rr.17U)oIthcLulxrrCodc,lshnll.li)nhwithcomplywilhllpsprovisi{)ns. <br />WARNING: Frilurc b sccurc w()rkcr\'conrpcnsalir)n e()vcragc is unlawlll. and shall suhjcct an cmpllycr k) (riminal lrcnxltics and <br />Scct()n -1{)7(r ol lhc Codc, inlcrcst und atkrrney s ltcs. <br />L-7 t1 <br />I hcrchy {llirm under pcmlly ol Frjury that I anr liccn*rl provisil[ of Chrplcr I (conlmming with Sccti(]n 7fim) ol Divisi()n 3 <br />{)l thc llu\inc\s and Prolc\si(ilrs Codc, ilil my lircnsc is in lirll lincc rnd cllccl. <br />Nu mh!a':o <br />CONSTRUCTION LENDING AGENCY <br />I hcK-by allirnr undcr Fn{lty ol F-rjury that thcrc is a constru(li(D lcDdins {gcncy l()r thc pcrlirrmancc ol thc wt)rk li)r which lhis lttnlit i\ <br />issucd (Scc. .1(197. Civ. C.). <br />lrrrrJer's Name : _ <br />[-cndcr's Addrcss: <br />APPI,ICANT DECLARATION <br />I lf,'rchy allim undcr pcnalty of fc{ury onc ol-thc li)lk}wing dcclnratn)ns: <br />Denr)lil()n Permits-Ashe{tos Nolilicali()n Ftdcral Rcgulalx)nr ('l illc 40. Prrt6) <br />_Required Ir(tcr of Nr)tilication <br />_l (crlity lhrt lh('ltdcralrcSulili(nrs rcciudint aslrc\k)s rcrnovxl ilrc nril appli(ablc k) lhis lrojccl. <br />_l ccdili that I havc rcrd this applicalion ul statc lhal lhc alx)vc inti)rmrtion is cotrccl. I agrcc lo comply with all City and Counly <br />ordinanccs and Statc l-aws rclding k) building conslructi(nr. ml hcrehy ru(horizc rcfrrc\cnlalivcs ol lhis Cily and Counly t) cnlcr uF)n thc <br />mntxrncd propcfly lirr inspcction PurF)scs. <br />or Agent <br />nxIt(,/ e,u iru t/ <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenVl nsulation <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 />llandicap Req. <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />FINAL Ylrlg,-n >-^. cy.,)'.dt) <br />Certif icate of Occupancv UI <br />Notes, Remarks, Etc. <br />-<o,r", tt/al/t ?