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BUILDING. INSPECTOR RECORD <br />\ <br />SITE.WORK DATE !D/SIG.COMMENTS OWNER IIUILDER DEI,CARATIoN <br />I hcrcby lllirm undcr pcnahy ofpcrjury lhat I on cxenlpt liom lhc Conlrack)rs' [,i(ensc Law for thc lblkrwing rcilson (Scc.70.]l:i <br />Busincss ond Profcssion Co.lc)r Any Cily or County which rcquircs n pcflrit k) coilstrucl. rllcr. inrprovc. dcnx)lish or rcpilir rny <br />slruclurc. priork) its issunrcc. also rcquircs the applica[l for such fErnril lo lilc a signed stalcnEnl lhal lrcor shc is liccil\cd pursuanl <br />k) lhc p()visioils of lhc Conlraclor's Liccnsed I.aw (Chapler 9. (i)nilncncing wilh Secli(rn 7{X)0 of Division 3 ol thc llusincss <br />ProltssionsCo(lc)ortharltorshciscxctrrptthcrclioman(lthcbisi\forlhcallcgedcxcilrplbn. AilyviohthDo,SccrionT0.ll.5by <br />applicaill li)r a Frmil subjccls lhc appliciltrt k) a civil pcnrlty of nol nlorc lhan Iilc hundrcd dollars (S5(X)) <br />ilild <br />rD'l <br />-1. <br />as owncr of lhe profrcny. or nly cmpl(,yccs wilh wrgcs !s thcir solc conrlEnsali(rn. willdo lhc s()rk and thc stmturc is ilol <br />irilcn(lcd orolltrcdf(rrsalc(Se.7(X4.BusincssandProfcssiotrsCodc:'IhcCoDlraci)r'sl-icenscLawdocsnolrpplyloanowncrof <br />the pDlrf,y who huilds or improtcs tlrcc)n. and who d(Ec such \t)rt him\clfor hcrsclfor through his or hcr owtr cnrpk,)ccs. <br />providcdthutsuch irnprcvcnf,ntsmnotincndcdorolleredl-osille.ll.howcvcr.tlrchuildingorin[rovcnEntisroldwilhi,roncyct <br />ofconplclion. thc Owilcr Buildcr will huvc thc hurdcn ofproving tlui lrc or shc did ml huih or inrprorc the proFny lbr tlt purfDs of <br />slc). <br />_1. as owner of thc propcrty. am cxclusivcly conlr{clirUt with Iicc[scd coillnck)rs k) con\lrucl lhc projccl (Scc. 7{H.1. []u\iilcss <br />and Profcssion (hdc: Thc (-'onlractor's Liccnsc [-aw docs not apply lo an owncr ofl()pcily who builds or inlprovcs lhcrcon. <br />rnd who conlmcts for such projccts with a Conlractor(s) liccilscd pursuilnt k) lhc Contraclor's Liccnsc lilw). <br />I xrn cxcrnnl undcr Scelioil . R. & P.C. li)r lhis reason. <br />I)a1c ()wner: <br />WORKERS' COMPENSATION <br />DECI ARATION <br />I hcreby allirm under pcmlly of pcrjury onc of lhe following declarations: <br />_l have and will truintain a Certillcalc of Conscnl lo Sclf-lnsure for workcrs' cornJrcnsali(nr, as providcd for by Section -1700 otthc <br />Labor Codc. for the pcrformancc of thc work for which thc pcrnrit is issued. <br />kllf,raveundwillm0inlaitrworkers'compcnsationilsurance.as requircdbySection3T0OoflhcLaborG)dc.lbrthcperli)rmanccof <br />'thc work for which this Jrcrmit is issucd. My workers' com[rcnsation insurancc caricr nM F)licy numhcr arc: <br />N /1a// <br />Pol icy to DD oo(>t o <br />_l ccnily thrt iil thc pcrli)rmdnce of thc work lbr which this ncrmil is issued. I shnll not crnpk)y nny pcr\on ir tny trranncr <br />so rs k) bcconE suhFct k) lhe sorkcr\'conrpcnsation laws ofCalilbrnir. nn(l agrcc thrt if I \houkl h(corm suhjccl t) llE <br />workcrs' cornpcnsrtion provistnrs ol Scclion .17(n ol lhc l-abor C'odc. I shall. lixlhrvitlr conrply wilh tlrrsc provisions. <br />IVARNINO: l:ailurc to scurc workers'compcnsation covcragc is unlasful, and shilll suh.icct an cnrpkrycr r) (Tinli[0] lrcnahics and <br />civil llnes up to onc huildrcd thousand (lollurs (Sl00.UX)). in additioI t(, lhc cosl ofcoirpcnsalion. thnugcs as providcrl lbr thc <br />Scction -1076 of the Lahor Codc. inlcrcst and otk)rmy s fccs. <br />,",", 7l*t I t {' - n**ti4lit*ihilJi /.y <br />I herchy aflirm undcr pcnillty of pcrjury lhat I anr liccnrd undcr provision of Chrptcr 9 (cotrnrrcncinE with Scction 7(xX)) ol l)i{ision 3 <br />of lhe Business and Piolcssiurs Code. and trrv liccnsc is ilr lull lbrcc lnd clfccl. <br />Liccnsc <br />l)atel <br />fi L-to *r,rr*, o) i{L( 7z' <br />1 tt,Contrector:[J 4v )-/ <br />CONS'IRUCTION LFNDING AGENCY <br />I hcrchy affirnr undcr ;rcnrlty of pcrjury thst thcrc is a c(illslrucli(,n lending flgcncy for thc pcrfornuncc of thc wrilk f(,r which this permit is <br />issucd (Scc. 3097, Civ. C.). <br />Lendcr's Namc: <br />Lcnder's Arldrc\s: <br />I hercby iliimundcr pcnrtry of pcrjury onc or,n" hffiffiffi <br />Defrrlitkrn Pcrmits-Asbcslos Notification Fcdcrul Rcgulalions ('Iitlc 40. Part6) <br />p$4Rcr;uircd t*tcr of Notifi calion <br />lLt <br />""rf <br />ify rtot ttc lcdcral rcgulations regsdirg ashesbs r€moval arc not apFrlicablc lo this pr)jecl. <br />fll ccrtify rhal I hovc rcad this applicution und state thal thc utx)vc iillbrmiltion is corcct. I agrcc lo comply <br />ordimnccs Bnd Statc hws rcluting to building conslruclion. 0nd hcrchy autlxrrlz rcprcscntativcs oflhis Cily <br />dtxrve rrcnti(,ncd propcny for inspcctt)n purF)scs. ,/ <br />AppricanrorAsenrs,r***, D\ //t a -Y , Dare:) <br />Pemrremnrerprint, Y*-t N 6 "7vfv <br />wilh All City and C()unty <br />xtrd Coutrly lo cnlcr ulnn lhc <br />Izlu <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVl nsu lation <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 Reo <br />Deputy Final Report <br />Enoineer Final Report <br />Flood Zone Certif <br />t,.,qh-76-lia I UL IL\) <br />F!NAL 4)<L1-r V <br />Certificate of <br />Notes, Remarks, Etc <br />#7 \