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BUILDING. !NSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS ()WNER I}UII,DI:R DI]LCARA'IION <br />I hcrchy affirnr un(lcr pcnahy of pcrjury thut I anr cxcrrlx liom thc Conlrnck)rs' Liccnsc Ltw for thc lirlkrwing rcrson (Scc.70Jl.5 <br />Businc\s and Profcssion Codc): Any City or CouDly which rftluircs r Frnril Io conslrucl. rllcr. improvc. dcmolish or rcpuir any <br />sttltcturc. prior Io ils issunncc. also rcquircs lhc applicuill for such pcrnlit lo filc 0 siglcd sl{tcnrcnt lhrl hc or shc is liccnscd purtuanl <br />ro lhc p(rvisions of lhc Contraclor's Liccnsed [:w (Chrplcr 9. Comnlcncing wilh Scclion 7{D0 ot Divisio0 -1 of thc Busincrs antl <br />I,rolcssionsCodc)orlhalh(orshciscxcnrptthcreftrnnrndlhcbasi\li)rthcrllcgcdcxcrnption. AnvviolationofScclionT0.ll.5hyany <br />applic0nllbrapctrnitsuhjectsthc applicflnlhilcivilpcilaltyolnoltrx)rcthrnlivchundrcddollurs(S5(X)). <br />_1. as owncr ol't hc pro;*rt y. or nry cnrph)yccs wilh wn8cs trs thcir solc conrpcilsilti()rl. will do llrc work aftl tlE stro1urc is nol <br />i!ilclxlcd or olltrc(l for salc {Sec.704.1. Busirrcss and ltnrltssions Corlc: l hc Conlracbr's [,iccrsc Law docs nol rpply b nn owncr ol' <br />lhcfRrltny whobuildsorin{nol'cslhcNn.altlwhodh-ssuchworkhiorsell'orhcrscllorlhrou8hhisorhcrouncnlployccs. <br />providc(l lhat such inlprovcnrcols ilc nol iilcndcd (n ofcrcd li)r salc. lf. howcvcr. lhc huilding or inprovcrrEil is sold wilhin onc ycnr <br />ofconlplctiol. thc ()wncr Buildcr will hnve lhc burdcn of provirg thal hc or she did trol build or inumvc lhc prcFEny for lhc purtb* ol <br />salt'). <br />_1. as o$'ncr of thc l)rofcfly. rilr cxclusivcly conlrilctinS wilh Iiccnscd conlrrclors to conslruct lh. pr()jcct (Scc. 7(ll4. Burincrs <br />and P[rltssiu Codc: 'l hc Conlrrclor's Liccnsc Law docs nol xpl)ly kr an owncr ()[pr{)pcrly wh() huilds or iilrprovcs lhcrcon. <br />rnd who contracts for such fojccls wilh a ('()nlrnck)(s) liccnsc(l pursunnl to lhc Contaaalor's Liccnsc Lxw). <br />I nilr cxcn)Dt uildcr Scclion-. u. & P.('. li)I lhis rcnso,t. <br />I)illr OHncrl <br />lY0 R K ERS' COlII PENSA TION <br />DECLARA'TION <br />I hcrcby ilffirtrr urdcr pcnally ol pc{ury onc ol thc li)lk)wing dcclnrnliols: <br />_l havc arxl will maintain d Ccrtillcntc ol Conscnl lo Scl[-lnsurc lirr workcrs' conrpcnsation. trs prl)vidcd lor hy Scction -j7(X) of lhc <br />t-akrr Cotlc. lor thc pcrlbrtruncc ol thc work for which lhc pcnnil is issucd. <br />{'/ thc tork thi$ pcrnril is issuc(l. My workcr\'and Jxrlicy nunrbcr arc: <br />L-- <br />t\,licy N <br />_l ccrtily that in thc lNrlbrnililce of the work for which lhis pcrnrit is issuc(|. I \hirll nol onploy dnt pcrson in any mrnncr <br />so {stoh€conlcsuhicctlothcworkcrs'coillpensatio[lawsol'Calilbrnia.andagrccthillifl\houldbcconrcsubjcctlolhc <br />workcrs'conlpcnutiouprovisionsofScctionlT(nollhclihrrCodc.lshall.forlhqilhconrplyu'ithllhscprovisiols. <br />WARNING: Failurc k) sccurc workcrs'compcnsali()n covcrrgc is unhwlul. aD(l shiill suhjecl an cnrpkrycr lo criminrl pcnrltics ilnd <br />civil llncs up to onc hundrcd lhousand dollnrs ($100.(xn), in ilddilion h lhc cosl of iort.'8"*'""'"lcc\. <br />I hcrcby affirn undcr pcnully ol Frjury that I am liccnrd undcr provision ol Chaptcr 9 (coilxrcncing wilh Sccli([ 7(X]0) of Division l <br />of thc Business nnd Prolcssions Co(le. and nry liccnsc is in lull lbrcc and cl-lcct. <br />l.i.cnsc (.iecnsc Nu <br />o,,",0{44 Contraclor(- <br />I hcrcby alllrtn undcr frcnalty ol pcrjury lhill lhcrc is ! conslruclior lcndiig a8cncy lbr lhc pcrtbnnance of thc work li)r which lhis Frmil is <br />issucd (Scc. .1097. Civ. C.). <br />hn(lcr's NanE: <br />I-cntlcr's Atklrcss: <br />AfILICANLDECLABAIIQN <br />I tmbyilfllnrundcr penally ofpcrjury onc ofthc lbllowing dcclarltions: <br />Dcnnlition Pcrnrits-Asbcstos Nolificalion Fcdcral Rcgulations (Tille 40. Pan6) <br />-Rcquircd <br />Lcllcr oI Nolificnli(]n <br />-l <br />ccrl ily lhal thc t'cdcrill rcgulalions rcgarling ashcstos n:rrx)vill xrc nol aPPli( nhlc l(r lhi\ Pr(riccl <br />{ ccnily rhar I hrlc rcrd thi\ xllticrl <br />/rrrlirranccs rntl Stutc Laws rclilinE to hui <br />nhovc ilErrlioncJ Firr'pcny lirr rnsg;ctionYAppli(ant 0r Agent Signolurc - /-\ <br />ion flnd stale lhal lhc ah)vc infbrnnli(ilr is co,rccl. I a8rcc k) conrply s'ilh illl Cily rnd (i)unly <br />I'rnililee ilanrc (prinl): <br />ilding conslructi(nr. nn(l hcrchy aulhorizc ""i,,'.,rffi'$u <br />Set Backs <br />Forms/Steeli Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVl nsu lation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />lMasonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />L <br />F!NAL 7/rrh tl ,,yMLi 1) <br />Certificate of Occu <br />Notes, Remarks, Etc <br />a \uO- I L6'ti A c <br />Applicanl: