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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG COMMENTS OWNER BUIl,Di:R DEI,CARA'TION <br />Iherchyaflirmunderpenalty..ofperjurylhatIdnexenrplfromthe('onlraclo6 l.icensel-arvforthefollowingremn(Sc.703L5 <br />Businss and Profssion Code): Any City or County rvhich requires a pemit lo construct. alttr, improve. dernolish or rcpair any <br />stmclure. prior to its issuance. also requirs the applicant for such penril lo file a signed statemml thal he or she is licmsed Pursuanl <br />to lhe provisions oflhc Contracrcr's l.icenscd tarv (('hapler g. ('onlnencing Nilh Sl{lion 700{) ofl)ivision I ofthe Busiiles and <br />I'rofessionsCode)orthatheorsheisexemptthdefrornandthcbasisforthe.llegedexemplion. AnyviolationofSstionT0ll.5byany <br />applicantforalnrnitsub-ielsthc applicanltoacivilpcnaltlofnotmorelhMfi\'ehundreddollars($500). <br />I.trs oNnsoftheftro[Erl].orrnyemploycssith\\'agsNtheirwleconlrcnsalion.rtilldothervorkmdthestrudueisnol <br />intsdd orofferedf<rsle(Sa.T044.lJusinssandProfcssi<rnsCode:'lhe('onlractor'sl,icensel,awdo6notapplyloanownerof <br />lheprct4fly rvhobuil<lsorimprorsthomn.iltd$'lmdo6srchsod<hintsclfrrrhoselforthroughhisorhoo*'nentploles. <br />prcvidcdthatsuch i,nprovonfllsuenotintmdsloroffqedforsale.lf.horvetr.lhebuiklingorimprovonentismldrvithinoneyw <br />ofcotnpletion. the Orvno Buildtr will have thc burdm ofproving that he or she did nol hrild or inprove the prcpsty for lhe pilrfF$ of <br />sle). <br />I. as ortner ofthe propqly. on exclusirely contr aclinB $'ilh licensed conlraclors lo consttucl lhe prejecl (Sec. 70.14. Businas <br />an<l [,[rfesion(irde: -IheContrack)r'sl-icenseLawdosnotapplytoano\\'nsofproperlyNhobuildsorirnprovestho'con. <br />and Nho contracts for such preiets *ilh a Corilracbr(s) licensed pursuant lo the Conlrack)r's l-icense Iaw). <br />-l <br />m exempt undo S(tion <br />Dale: _ <br />lJ.&P(.lbrthisrcason <br />()n ner: <br />\\'oRKt,iRs' ( ()l\l l'1,:Ns,\'il( )N <br />l)I'( 1.,\l{,\'l lo:i <br />I hereby aflirm under pcnalry ofpojury one ofthe ftrllorving declualions: <br />I have md will malntain a Cstificate ofConsflt to Self-lnsure fo workos' compos.tion. as provided for by Section 3700 ofthe <br />l-abor Codc. for the pafonnance ofthe rvork for which lhe pmnil is issucd. <br />I har.e and rvill maintain s-orkos' compensalion insurance. 6 required hy Srction 1700 ofthe l,abor Code. for lhe psftrmance of <br />the work for which lhis pernrit is issued. My rvot*as' comp€nsalion insurance cmio od policy numbo ue: <br />Cario: <br />Policr. Nunber:Hrpilcs' <br />I ccfify that in thc pcrfonnance ofthe rvork for $hich lhis perntit is issucd. I shall nol pcrson in aill. rnanner <br />so as to lxcome subiccl to llrc Norks's'coil]pcnsali{)il las's ol (ancl agree that iI I subjcct to lhe <br />provisionsrvorkcrs' compcnsalion pror isions ofSrclit'il 1700 oflhe Latxn (I shall- fonh\! ith <br />WAllNlN(; lraillle lo sc(ure \\orkcrs' co,rlpeilsali()n lasful. anrl lo crinrinal Brrahies drrd <br />ciril fines up k) one hilndred lhousand dollar in i(nr k)as proridecl for the <br />Secli(rn -1076 ofthe t-ahlr ('odc. irilersl and flltlnrcy s [ces. <br />[)r1(: <br />Dl,.( 1.,\ll,\ I IoN <br />I hcrcby allir m rrnder l)cnalt\ of pq illr! lhal I a,n licensc(l iln(lcr pr or ision ((ommcncing \r ith 7(X)0) ()l Di\ rsion I <br />of lhe Busin6s and I'rofssions ('odc. ad my licensc is in ful <br />[-iceilse ('lass: <br />Drtel <br />N <br />I hercby- aflirm under lrcnaltv of perjury that lhq'c is a conslruction lcn<ling agcncy ol thcurrrk lirr uhichlhislnnrit is <br />issucd (Scc. l0()7. ('i\. C.). <br />lm(lcr's Nanre: <br />l.cnrlcr's Arldress: <br />APPI,ICANT DECI,ARA'IION <br />I luehy allirrn uncler pcnalty of pet iury one r)f lhe lbllo$ ing d$lataliotlsl <br />I)ernolition PenDits-Astrstos Notification l'eleral Regulations ( I illc '10. Parl6) <br />- Required [.ctlerof Notification <br />I cqtil! lhrt lhc lcdcral aslreslos to lhis projecl. <br />I cdlil'y lhal I hare rca(l lhis lhat lhe I atlrN lo cornply lvilh all ('ily and ( ounty <br />ordinailcs ilod Slate [.as's relaling lo <br />almve rnenlirned propcf,y for inspecl <br />i\ 6 ofthis City and Counl! to cnts upon lhe <br />Applictrnt or Agctrt Sigtrature: <br />l'crnrilrc ilsilrc (priil,,, Lll ft<r1 <br />irrn. and <br />lriltc:8 ZZ,\1 <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subfloor/VenUl nsulation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Enerqy <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 />I /1 <br />FINAL h o 0 !lnn <br />Certificate of <br />Notes, Remarks, Etc. <br />( otrlrlclor <br />I