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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/Enerqv <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />---\ <br />FINAL 2l?/617p tu?9/</Certificate of Occu <br />Notes, Remarks, Etc <br />BUILDING- INSPECTOR RECORD <br />I hcrchy allirm undcr pcnully of pcrjury thsl I am cxcmpl lion lhc Conlracmrs' Liccnsc [rw for lhc following rcaso[ (Scc.?0Jl.5 <br />Busincss antl Profcsshn Code): Any City or CouDly which rcquircs a Jrcrntil lo conslrucl. altcr. improvc. dcmolish or rcpuir any <br />structurc. pri(tr Io its issuancc. rlso rcquircs lhc applicant li)r such Frrnlil lo filc a siglcd slalcnrcnl lhat hc or shc is licc[scd <br />lo thc provisions of thc Contrack)r's l,iccnscd tiw (Chaplcr 9. Conrrrtcncing with Scction 7(x)0 of Division .'] of the Busincss <br />P()lcssiotrsCodc)orthalhcorshciscxcmplthcrefromandlhchasislbrlhcallcgcdcxcnrpli(D. AnyviolalionofScctionT03l.5by <br />ilpplicrntli)rrpcrmitsuhjcclslhc applicantloacivilpcnrllyofDotmorclhanfivchundrcddollars($5U))i <br />-1. <br />as owncr of thc proJEny. or my cmployccs w ilh wxgcs ns lhcir so lc con{rcnsnt i()n. will do lhc work and tlrc slruluc ri not <br />inlcrdcd orollcrcdlorsalc(SN.T044.llusircssundProfcssionsCodc:lhcConlrrctor'sLiccnscLawdocsnolapplyk,anowncrof <br />lhc proFny who huilds or hnpro\es thcmn. md who dms such trr)rk hinr\cll or hcrscll or Ihrough his or hcr own cnrployecs. <br />providcdthxlsuch improverrcntsarcnolintcndcdorolltrcdl'()rsillc.ll.howcvcr.lhcbuildirrgorimprovcrrcnlissoklwilhinrnlcycilr <br />ofconr|)lctknr. thc Owncr Buildcr will havc thc burdcn ofprovirrg thd hc or shc did nol buikl or hnprovc thc prolffiy l-or lhe purfx)sc of <br />salc). <br />_1. as owncr ol thc pro1rcny. anr cxclusively contrdclirg trilh liccn\cd conlrack,r\ lo con\lrucl lhc pr)jccl (Scc. 70.1.1. Busirrcss <br />and F\ofcssi)n Co(lc: Thc Conlruclor's Liccrrsc Law rloes nol apply lo an owncr ofpropcrty who builds or itrlprovcs thcrcon. <br />and who conlrncts lilr such [)r+cts with a ('orilrilctor(s) liccnscd pursuanl k) lhc Cuilruck)r's Liccnsc hw). <br />lamcxcilrDlundcrscclioD-.B.&P'C.forthisrcas0[. <br />I)illr ()s o(,r:"*ffiffi <br />I hcrchy afllnn undcr penally of Frjury one ol thc folk)wing dcclarrlions: <br />!f huvc unrl will rroinrrin a Ccf,ificutc o[Consent lo self-lnsurc for x'orkers' conrpcnsllion. as provided lbr by Scclior 3TtX) ol the <br />t tx)r Codc. lor lhe pcrforiluncc of lhc work for which thc lcrmit Ls issucd. <br />4auc anl *lll maintain workcrs' coilrpensation insurarrc. as rcquircd by Scclion l?(X) ol the Libor G)dc. lbr lhc pcrfornmncc of <br />lhc work for which this pcrmit is issucd. My workcrs' compcnsation insurnncc cnfficr ild policy numbcr uc: <br />,.^r,",,2 Uf iCl.- <br />,",,,yt"^*,, lPc l0boQ4626 t.pi,*, o{-Zl- Zazc) <br />-l(l ccnify that in thc pcrfornuncc of thc work for which this permil is issucd. I shall nol employ any person in any nunncr <br />so as lo bccornc subject b lhc workers' compcnsation laws ofCaliforoia. and a8rec thal if I should bccome suhjccl k) lhc <br />workcrs'conrpcnsationprovisionsofScclion3TU)oflhctntnrCrxlc.lshall.fonhwilhcomplywilhlho*prcvisions. <br />WARNING: Failurc to scurc workcrs'compcnsation coverage is unlawful. and shall subjccl an employcr to oiminal lEnahics and <br />civil llnes up to onc hundrcd tholsand dollars ($l{n.fiX)). in additiotr lo thc cost ofconrpcnsation. dailugcs a$ providcd for the <br />Seclt)n -3076 ofthc t tx)r Codc. intcrcsl and attoflEy s fccs- <br />ou.", 1/l= <br />I)FCL{RATION <br />I hcrchy allirrn undcr pcnahy of pcrjury that I lrn liccnscd undcr provision of Chtrptcr 9 (connrtncing wilh Section 7(Xx)) of Division -l <br />of thc Busincss and Proltssio0s Codc. imd rny liccnsc is in lirll forcc iurd ctltcl. <br />t-ic""."ct"*, ,{+ B l-iccnscNunrhcr:oq <br />o,r",OI-ZZ-? <br />CONSTRUCTION LENDING A(;ENCY <br />I hcrcby afllrm undcr pctralty of pcrjury that thcrc is a construction lcnding agcncy for the pcribrroncc of thc work for which this pcrmit is <br />issucd (Scc. 3097. Civ. C.). <br />knrlcr's Nurnc: <br />l-cntlcr's Arldrcss: <br />APPLICANT DFCLARATI(IN <br />I lnruhy alfirm uDdcr penalty of pcrjury onc of thc lbllowing dcclaral ions: <br />Denx)lition Pcrmits-Asbcslos Notificalion Fcdcral Rcgulati([s (Tillc 4(]. Pail6) <br />_Rcquircd [.Icr of Notilicali{)n <br />_l ccaify rhat thc fcdcrsl rcgulalions rcgtrding ashcstos rcrnoval arc nol applicrhle k) this prejccl./ <br />-lzl ccnify rhxl I havc rcud lhis applicalion and slalc that thc iltnvc informatkil is corcct. I agre to cotrlply wilh flll Cily dnd Counly <br />ordin{nccs and Slatc hws rclfllinS lo building construction. ilnd hcrcby authorizc ivcs of lhir City an(l Counry to cntcr uFrn thc <br />ilbovc nrcnti()ncd pft)l)crty li)r inspcct <br />Applicilnl or Ageilt <br />I'crnrilrr trxtrrr (l)ritrl): <br />iort <br />o,,",Ol'LZ'4 <br />@4pri*nt,