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BUILDING. INSPECTOR RECORD
<br />DATE ID/SIG COMMENTSSITE-WORK
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framinq
<br />lnsulation/Enerqy
<br />Drywall z./dr,>tr<-zl
<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 />ZCt5ztF!NAL -7,,18,/,?-r ,*45 )/4
<br />Certificate of Occupancy / '
<br />Notes, Remarks, Etc.
<br />IherebyaflrnrunderpcnallyofpedurythatIameremptfrcmtheC'ontretoN l-icensclawfo.th.followittSrca$n(5@.7031.5
<br />flusincss and Prolcrsion Codc): Any City or C()untv which requircs a lrrmit lo conslruct, allcr. irnprovc, dermlish or rcpair aay
<br />stnrctrrre. prior !) its issuancc. also requires the applicant t()r such pemlil k) nh a sigiled slarernenl lhat lrc or she is lice[Ed pursant
<br />h rhc pmvisions ol thr' Conlractor's l,icenscd liw (Chaptcr 9. Cornmcncing wilh Section 7{XX) of l)ivision 3 pf lhc Business and
<br />ProftssiorsCode)orthatheor\heiscrenrpttherefionrandthebrsisti)rtlNallesedexen)pliotr. AnyviolationofSectirrT03l.5lyany
<br />npplicrDt for a pcnnit subjects rhe ilpplica0r lo r civil pcnahy oI nol nrre thrn llve hundrcd dolhrs ($5(I)).
<br />_1. as owncr ol-lhc proFny. or my employccs wilh wagcs as lhcir solc cornpcnsation, will do th€ work and thc stMlurc is mt
<br />irlenlql or offcrerl for sle (Se.7(X4, Busincss and Prcfessions Cql€r Tha Contrrcbr's Licensc Law does nol apply to an owncr of
<br />theprupeny wlx)buildsorimprovesllEmqailwlDd(tssuchworkhimselforltrselforlhrou8hhirorherownemployees,
<br />providcd that such improvcrmnts ac not intendcd or ollcred for salc. ll, howcver, thc building or improvcmnt is sold within onc yc{
<br />ofcon{}lctim, tlE Owrrcr BuilJs will luvc thc burdcn of poving lld he or she dirl m build or impmvc fie pmpoty for tlrc purpoe of
<br />salc).
<br />_1. ns os,rcr ofth€ propeiy, am exclusively conlrscting wilh licensed conlraclors k) con\lrucl lhe prcject (Sec. 7(N4, Business
<br />aril I'xrtbssrrnCode:TheCoiltract()r'sLicenseLawdoesfttrapplytranowncrofpropertywhobuildsorin)!()vesthereon.
<br />nnd who conracrs for such proi.'cls wilh a Contrach(s) liccnscd pursuant lo lhc Coolridor's Liccnsc Law).
<br />-IJn]exenllnUndcrSeclur-'B'&P,Cti)rlhisrea\{nl,Ihte:_
<br />WORKIIRS' ('ON{PUNSA'I lON
<br />I)I]CI,ARATIoN
<br />I hcr!'hy altirm undcr pcnaly of pcrjurv (,nc ol thc lbllowif,g (lcclarari()ns:
<br />_lhaveandwillnnintsinaCeflificateofconsentnSalf:lusureforworkcrs'contpensation,as pruvirledforhySectionST00ofthe
<br />Lrhor Codc, for lhc pcrforrurcc oflhc work lbr which the pcrmil i\ L\sued.
<br />and will nraintairr workers' conlp€nsltioil insurancc, as required hy Section 3700 ofthc Lxbor Clode, for thc perfomuree of
<br />lhc work li,r whi(h this pcrmit is issuc'd. My workcrs' conrpcnsatirn insurancc cafii€r uxl lx)licy nunrhcr are:
<br />Pnli.y Nurr$et'. t'.,pi,er'-
<br />_l ccnity that io thc pcrtbrnuncc of thc work li)r which this pcrmit is issucd, I shall not cnlploy ilny pcrson in any manncr
<br />so as h bcconE suhjccl to thc workcrs' conrpcnsatiur laws ol-Calil'ornin, and a8rcc thBt if I should bcco,ft suhjcct to thc
<br />workers'conrpensxtionprovisiuNofSectionlT00oftheLaborCode,lshall,fonhwilhconrplywiththosprovisions.
<br />WARNING: Failurc rc $curc workcrs'conrpensilion covcnrgc is unlawf!|, and shall suhject an cmploycr t) cnminul lrcMlties rnd
<br />civil liner up k) onc hundred thousand dollArs (Slo(!,{xxD, in nddition lo lhe cosl ofconrpcnsrlion. darnrgcs .s providcd lbr lhc
<br />Sc.li(D .1076 of the Codc. iilerest and
<br />I)I.l('l.ARAl t()N
<br />I hcrcby allirm under penalty ol pcrjury that I am licen*d undcr provision ol Chapter 9 (commncing with Section 7fin) of Division I
<br />of thc Business and Prcfcssions OxIe. ruxl nly liccnse is in full f()re iuxl clfect.
<br />Liccnsc E Nurntt'r'4V3/ot
<br />I heRhy allirn) under ltnahyofperiury that lhere is a agerrcy the pcrfolmk-e of the work tbr which this fEmil is
<br />issued (Sec. ll)97, Civ C.).
<br />Irndcr's Nnmc:
<br />l-r'ndcr's Arklrcss:
<br />APPI,ICANT DECLARATI()N
<br />I lrEby afiim) under |rcnalty of pcrjury one ofthe following drelaratiotrs:
<br />Dcnrolirion Pernits-Asbestos Ndification Federal Regulatiohs (Title,l0, Par(6)
<br />_Required Irlter of Notificalion
<br />_l cediti that the f'ederal rcgulaiiom rc8udin8 asbcstos rcmval are nd applicablc ro rhis prujet.
<br />rhil application iurl state thal the abo\e infomration is corcct. I ngr@ to conrply with all City anrl County
<br />()rdi,Hilccs aod k) huikliDg coDstructi()rr, and herehy uuthorize rqrrescntatives of this Cily and Coutly b enter uFrl tlE
<br />atx)!c nrcnt(rncd
<br />Applicanl or A8ctrl
<br />l'rnniler ndilr(
<br />li)r
<br />,3 a,
<br />Rev.0B-07-2015
<br />(larier
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