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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DI]I,CARATION <br />I hcrcby alllrm undcr pcnalty of lErjury thal I iln cxctrrl, liom thc Contrrckns' l-iccnse lnw fbr lhc lbllowinS rcrson (Scc.70-11: <br />Busincss and Proltssion C<xlc): Any City or Counly which rcquircs d pcrmil k) coilstrucl. rhcr. inrprovc. dcmolish or rcpuir any <br />rlruclurc. pri()r k) its issuuncc. also rcquircs thc applicant lbr such Jrcrtrrit lo filc a signcd rtatcrrcnl lhrt lrc or shc is liccn\cd pursu{nl <br />l(, thc provisions of thc Conlrilclor's l-iccnsctl Law (Chaptcr 9. Conrnrcncing with Scclion 7(NX) oI Divisioil 3 of thc Busincss,and <br />ProlcssionsCode)orlhnthcorshciscxcnrilthcrc,ionlilndlhchusislorlhcdllcgedcxctrrplion. AnyvidalionofScctirrnTo-il.5hyar.; <br />applicu0tlorapertrritsubjccts(hc applicantk)ilcivilpcnrllyofDoltrx)rclhanfivchundrcddollrrs(5500). <br />_1. ar owner of lhc profrcrly, or Dly cmployccs wilh wrgcs rs lhcir solc coilrpcnsalion. willdo lhc work and thc slrulure is D()l <br />intcndcd orofl'crcdfbrsalc(Scc.7()44.BusincssrndProltssionsCo(lcrTheC'ootruck)r'sLiccnscLilwdocsnotapllyk)ailowtrcrof <br />lhc prolErly who builds or improvcs lhcrmn. rnd who dcs such work himsclfor hcrsclfor IhrouSh his or hcr own cmployccs. <br />providcd th{t such inrprovcnrnls f,rc nol iilcndcd orofTcrcd lirr ulc. ll howcvcr. thc buikling or improvcrrrilt is skl wilhin onc ycar <br />ofconplctirl llE Owncr lJuiklcr will hlvc thc hurdcn of proving lhilt hc or shc di(l nol build or irnprovc lhe pn)pcrty li)r thc purJx)sc of <br />salc). <br />_1. as owner of thc propcny. flm cxclusivcly contracting wilh liccnscd conlrack)rs lo construcl lhe proiccl (Scc. 7()44. Bu{incss <br />ilnd l\)lission Codc: l he Contractor's Liccnsc Law docs nol apply to an owncr of properly who builds or iNprovcs thcrcon. <br />rnd who conlructs lor such projccls wilh a Corltracknls) licenscd pursuunl lo thc Contrnctor's Liccnse Law). <br />I rnr crcnrpl un(lcr B. & P.C. lbr lhis rcasoil. <br />l)ale:()$ner: <br />WORKERS' C(INIPENSATION <br />DECLARA'TI(IN <br />I hcrcby allirm undcr pcnalty of pcrjury onc of thc lollowing dcclaralions: <br />Il havc md will nuintain a Ccrlificate of Coilscnt to Sclf-lnsurc lt,r workcrs' conrpcnsation. as providcd ti)r by Scction -j700 ol lhc <br />llhor Codlz{lliihc pcrforililrcc (,f thc work for whi(h thc pcrmit is is\ucd. <br />ff,avc ancl will maintdin workcrs conrpcnsalt)n insurancc. as rcquircd hy Scction .17U) oflhc tihor Codc. for lhc perfortruoce of <br />lhc work li)r which lhis l^-rmit is issucd. My c()ntl)cnsilli()n policy nunrhcr arc: <br />L o <br />Policy a 55 lo J--) <br />_l ccrtily lhlt in thc pcrlbnnancc of thc work tor which this pcnnil is issucd. I shrll not enrpk)y dny pcrson in aily nunncr <br />so ns to bcconrc subjcct m thc workcrs' compcnsat i(,n lnws of Cdlili)rnir, an(l agrcc thut if I should bccotrrc subiccl t) th! <br />workcrs' conrfensiltioil provi\ions ofScction l7(n oIthc Latnr Codc. I shnll. lonhwith comply wilh tho$ pfi)visions. <br />WARNING: Failurc to *curc workcrs'conrpcnsalion covcraSc is unlawlirl. {nd shall subjcct un crnpkrycr b triminill pcnallics ud <br />civil lincs uf lo (nrc hundrcd thousund dollars ($lU).(XX)), in addilion k) lhc cost ofcoilrpc[siltir)n. (lrrnagc\ us prrrvitlcd for thc <br />Scction .1076 of ihc t-utxtr Codc. irilcrcst trnd alk)rncy's lics. ,a,2 , N i <br />Da(e-:? - ].a]-2- Appri,nr: * - 1A-, Wd ){L,- <br />LILTNSEII CONTRACI'OR 'DECLARATION <br />I hcrchy nlllrh under pcnillty of lErjury thnt I am liccnscd under provision of Chaplcr I (coDurencing with Scction 70fi)) oI Division -1 <br />of lhc Uusinc\s rn(l Prof-essions Code- anrl mv liccilsc is in full lorcc aml ctt'cct ' <br />l-iccnsc ,Nnnllrr:a I s 1L <br />n"r", ' /, )-j (irntrlclor: ( <br />CONSTRUCTION LENDING A(;ENCY <br />I hcrcby alfirm under ;rnalty of pcrjury that thcrc is a conslruclioil lcndirrg agcncy tor thc pcrlortruncc of thc work for which this pcrmil is <br />issucd (Scc. 3097. Civ. C.). <br />llndcr's Natrre: <br />l-cnrlcr's Arlhcss: <br />APPI ICANT DECLARATTON <br />I lmjty allirm under penalty of pcrjury onc of lhe li)llowing dcclarations: <br />Dcm)lilion Pcilnits-Ashcslos Nolification Fcdcral Rcgulations (Titlc 40. Part6) <br />-Rcquircd <br />hllcr of Nolificslion <br />I ccnily lhal lhc fcdcrrl rclulxtionr rcgdding astEsk)s rcrnoval rrc Dot applicablc n) this projcct.^lr-7-[t ccrrlty rhrr I havc rcad lhi\ application and slatc lh{t thc ahovc infornution is corcct. I ngre to comply with all City and County <br />ordirranccs and Stale Laws rclating to building conslruction. and hcrcby authorizc/cprcscntativcs (,fthis City tnd Counry to cnlcr !F,n thc <br />ak)vc ilrcnti(,ncd propcfly for in\frcction purlnscs. ,/') A I <br />ApprcaDrorAgeDrs,*n",u*, X Z. VI[L}$--- Dur", , i ^J \)o <br />l'crnriler nnnre (prinl):l- untt'r-(o/ <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/Vent/l nsu lation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />lVasonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />F!NAL *?z-u )^1 lor <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />-l