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SITE.WORK DATE ID/SIG COMMENTS <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 />JMasonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif. <br />FINAL qr-a2d //Ci 5Nt za) 2/) <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />-1f,-lozb't ( <br />Tt2 a <br />2 -20 z <--t /e <br />L <br />OWNER BUILDER DELCARATION <br />IhcrehyallirmundcrF-nallyolpcrjlrylhalIamcrcn]ptli1)mlhcC{)ntracloF LiccnseLawlbrthcli)llowingrcason(Serj.70-11.5 <br />Business and Prolcssion Codc): Any Cily or C()(nty which rcquircs { pcrmit lo c()nstrucl. altcr, inlprove. dcmolish or repat any <br />sltucturc.pd)rt)its issuincc,alsorcquircslhcapplicnnllbrsuehlrcrhitk)lilcasigncdstxtcnrcnt thathcorshcisliccnscd pursuant <br />k) thc provisions of thc Contrack)r's l-iccnscJ Law (Chrptcr 9, Commcncing with Scction ?Uru ol Division .] of the Busincss md <br />P()ltssionsCoJc)orthathcorsheiscxcmptthcreft)mandthcbasisforlheallcgcdcxcmptil)n. Anyv()lationolScctionT0,ll.5hyany <br />applicanl li)r a pcrmit suhjccts thc applicant k) a civil pchdlty o[ not morc than livc hundrcd dollars (S5m). <br />.J <br />_1, as owncr ol'thc p(rpcny, or my cmployccs wil h wages as t hcir solc conrpcnsation, will d() thc work Md thc strucluc is not <br />incndcd orotltrcdti)rsalc(Scc.T044.BusinessandProlassionsC(rlc:'lheContrack)r'sLiccnsellwdocsnotapplyk)ilowncrof <br />lhc pnlJtny who huilds or impmvcs lhcrcon. md who d(Es such work himsclf or hcrself or through his or hcr own cmpkryccs. <br />providcd thal ruch improvcnEnls re ftil iilcndcd orollcrcd tbr salc. If, h)wcvcr. thc builling or impmvcmnt is soLl within,,nc ,td <br />ol comflction, thc Owncr Builder will hdvc thc hurdcn ofprrving lhat hc or shc did not huild or itnprovc tic pn)frcay lbr thc puryDrc of <br />salc). <br />_1, as owncr ol'lhc lrropcdy, anr exclusivcly eontrarling with liccnsed qrntractors k) constnrct thc p()jcct (Scc. 7044. Busincss <br />afrl Pnllbssiln Codc: fhe C()n(r!ck)r's Liccnsc l-aw docs not apply k) rn owncr ol property who builds or improvcs thcrcon, <br />and who conlracls li)r such projccll with a Contrack)r(\) liccnserl pur(uanl k) thc Contrack)r's Liccnsc [aw). <br />_l atrl crcntpt uDdu'I1 & P (l li)r lhis rcr\on <br />/)-.-... <br />lvonrBns' cottrrns,ttF <br />DECLARATION <br />I hercby alfirm u mlcr pcnalty of pcrju ry onc of the ti)llowing dccltral ions: <br />_l have ud will maintain a Ccnificale of Conscnl k) Sclf-ln:ure li)r workers comlcnsation. as proridcd lirr hy Scction J700 of thc <br />Lak)r Codc, tilr thc pcrlormancc of thc work tor which thc pcmit is issucd. <br />_lhavcandwill maintainworkcrs compcnsalioninsurancc,as rcquircdbySeclion-lT00ofthcljborc()dc,forlhclertbmanccol' <br />thc work ti)r which this lrcmrit is issucd. My workers comfrensrtion insurance cuicr and grlicy numbcr uc: <br />Policy N c6 ,07^/0- t-/ I <br />_l ceilili lhal in thc t--rlornunec ol lhc work li)r which lhis pcrilrit is issucd. I shall r()t cnrploy rny pcrson in any mrntrcr <br />s() as k) hceorrc subjccl k) thc w()rkcrs' conrpcnsal ion laws of CrliforDix. and rgrcc l hat if l should hcconr suhject t) thc <br />wr)rkcrs'c(nlt^-n\ali(mprovisirmsol'Scctir)n.17(X)olthckhrrCrxlc. Ishall, lonhwithcomplywiththoscprovisions. <br />IVARNIN(ir Fiihrre k) s('curc wrn'kil's'eompcnsali()il eovcrr{c rs shall suhjcct rn cmphycr k, crinrindl fEnaltics and <br />civil Iincs up k) ()nc hundrcd thousxnd dollds ($lm.0m), in (,1 conrpcnsrtion, rlanragcs as lrovklcd i'r)r lhc <br />Scclion .107(, of lhe Lahrr (ix.lc. iilcrcsl and xlt)rney s lccs. <br />r>^r".' /' 1' I 7 <br />I hcrchy allirm unrler 1)cnalty ol pcrjury thtl I am liccnscrl ( hillcr 9 (eomnrcne rn8 with Sce(io0 7(xX)) ol Division .l <br />ol thc Bu\ircss and Prolcssi()ns Crldc. and mv licensc is in llll lorcc and clli.c(. <br />t0l <br />t)ure:' /-Z- t "l <br />CONSTRUCTION t,ENDIN(I AGENCY <br />issucd (Scc. .1097. Civ. C.) <br />I"cnrlct s Nanrc: <br />[rndcr's Addrcss: <br />APPLICANT DECLARATION <br />I lFrchy rtliin undcr pcnalty of pcrjury rnc of thc li)lk)wir)g dcclxrrtir)ns: <br />Dcn()lilion I'crmils-Ashcslo\ Notification llcdcral RcSulations (Titlc 40, Pan6) <br />_Rcquircd [-cttcr ol' N({ilicali(tr1 <br />_l ccdili that lhc lcdcrrl r(-gulati(nrs rcgrJing ashcsnrs rcrnoval nrc nol ipplicahlc to this proicct. <br />/il ectity rhtr I hrvc r('rd rhis apphcat <br />ordrninecs and Stalc Laws rchting lo bul <br />ion ilxl statc thrl lhc ali)vc rnli)rnult)n is conecl. I agrcc lo ()mply with all City and County <br />aulhr)rizc rcprcscntutivcs ()l this ('ity and County to cntcr uF)n thc <br />rtx)\'c rlNntt)ncd pr)l--dy li)r uspccli(nr <br />Applicnnl or Agent <br />I'ernrilcc Dailrr (pilnl ) <br />rldrng <br />{ <br />-2-r <br />BUILD!NG. INSPECTOH RECORD <br />Date:_