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DATE ID/SIG.COMMENTSSITE.WORK <br />Set Backs <br />j v-v fiaForms/Steel/Holdowns (,u \-/Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf 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 />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />/\l(-/?-l{,/\\ <br />F!NAL <br />Certificate of Occu <br />Notes, Remarks, Etc. <br />()\\'NIiR lllrll.l)l,llt l)Ial.(,\llA l ()N <br />ir;[:; *lr l"i"i]rr.,:t <br />I hcrchy allirrt undcr pcnrhy ()l pcljury lhill I lm cxcoll, liont lhc Cl(tnlrxcl(,rs' l-iccilse [dw i)I <br />Busincss and Profcssion Codc): Any Cily or Counly which rcquitcs a lEnnil lo c(tnslrucl. allcr <br />structurc. prior Io ils issunncc. also rcquirc\ lhc applicanl lirr \uch lrcrillil lo lilc a si8ncd slatciltnl <br />k) thc provi\ions of tlE CoDtractor's Liccnscd hw {Chaptcr g. ('ommcncing wilh Section 7(XX) ol Division J oi thc Busincss aDd <br />P()lts\ion\Codc)orthiltlrcorshciscxcmptthcrcfronlundlhchit\islhrlhenllcgcdcxcnlplion. AnyviolalionofScctt)n70.ll.5bylny <br />npplicnnt li)r u pcrmil suhjccls lhc applicilnt lo 0 civil Pcnillly of 0ol trDrc than fivc hundrcd dollrrs ($50o). <br />_1. xs owilcr of the prolrcfl y. or my cntpk)yccs with wogcs as I hcir solc cornpcDsil iorr. will do lhc work und lhc sltulurc is not <br />iilcRlcd orollcrcdfor$lc(SN.7{}44.BusincssandProltssionsCodc:ThcC()0lrilchr'sLiccnschwdocsnotapplyloanowncrof <br />lhcpn)Nny wlx)huildsoriillp()rcslhcrq)n.xndwhodocssuchurrkhinrsclIr)rhcrscllorlhrou8hhisorhcrowncmphyccs. <br />providc(lthalsuch impr()\!ilrntsircnotiilcndcdorofTcrcdti)r\ulc.lf:howcvcr.lhchuildingorinrProvcntnlissldwithinonclcur <br />ofconlplction. thc Owncr lluilder will havc thc burdcn of proviilS lhnl hc or shc did nol build or improvc lhc prtfrcny for lhc Purlnse of <br />_1. as owncr of the propcrly. ail cxclusivcly contracting with liccnscd conlraclors lo cotrstrucl llrc p()jccl (Scc. 7044, Bt\incss <br />aRl th{a\si()n Codc: 'l hc Contracror's Liccnsc Law docs Nil nfrply lo an owncr ofprofcrly who huilds or improves lhcrcon. <br />and who contracts li)r such projects wilh a Conlracm(s) liccnscd pursunnl to lhc Contractor's Liccnsc ljw;. <br />Iilllre\crllplun(l.rsc(li()rl- l]'&l'('l()rlhi\leil\t)ll' <br />I)nlr ()titrcr <br />1\'( )RKtaRS' (',()l\IPENSAI'lON <br />pract-ARAlroN <br />I hcrchy nl'llrilr undcr pcnalty of pcrjury onc of thc following dcclatations: <br />_l havc and will nEinhio tr Ccnificalc ol Conscnl to Self-lnsurc lbr workcn' conlpcnsation. as prcvidcd tbr by Scclion .U(n of the <br />[jtx)r Codc. lbr thc frcrfoilEnce of lhc work for which lhe Pcrmil is issucd. <br />_lhrvcnndwillmaintainworkcrs'comJrcn\nlk)ninsurance.as rcquiredbySccliol:]T0OotlhcL{horCodc.forlhcpcrfornunccof <br />thc work lirr which this permit is issuc{. My workcrs' contpcnsalirrn insurancc cafticr aM Fnlicy nunlbcr trc: <br />Policv Nuilrhcr: F.\Pircs: <br />- <br />_l ccrtily that in thc pcrlbrmililcc of thc w()rk for which lhis pcrnrit is issucd. I shall not cmpk)y any pcrson hl any manncr <br />so ils tr bccotrrc subjcct kr thc workers'cotrrpcnsrtion laws ofCalifornia. and agrcc thnt ifl should hcconrc subjcct b thc <br />workcrs'contpcnsationprovisiorsofSeclion3?fi)ofthcLih)rCodc.lshall.lirilhwilhcontplywilhlhoscProvisions. <br />WARNINO: I-ailurc lo sccurc lvorkers'corrlpcn\alion covcragc is unlilwtul. rtrd shall subjccl iln lo crinlinnl pcnxllics rn(l <br />civil fincs up b onc hundrcd thousand dollars in lo lhe c()\l of xs ptr)vi(lcd tbr lhc <br />Scclion J07f, of thc litx)r ('(xlc. inlcrcsl s fccs. <br />Dste: <br />pror iskrn oI Chrptcr 9 (conrnrcncing wilh Scclio0 7(XXl) ol I)it'isi(,n .]I hcrchy allirtrr undcr pcnally of pcrjury lhal anr liccnscd <br />ol thc Busincss aild l'roltssbns Code. ud nry liccnsc is in lull forcc n[d eflccl. <br />l-icotrsc <br />l)nie: <br />I hcR'hy nt'llrtrlundcr lttrrhyofpcrjurythat thcrc is a conslnrclioil lcnding agcncy lirr thc perlbrtuncc ol lhc work li)r which this pcrnil is <br />issucd (Scc. 1097. Civ. ('. ). <br />l-erxlcr'\ Nrnrc: <br />Lcn(lcr's Addrcss: <br />ATILICANI-DEEI.AEAIIQN <br />I lmby rllirln undcr pcnalty of pcrjury one <)f lhe followilrg dccktrllions: <br />Dcnx)lili()n Pcflnils-Ashc\tos Notillcalion lrc(lcral Rcgulalioils ('l illc '10. Prrl6) <br />-Rcquircd <br />l,cllcr of Noliticati)n <br />I ccrlily lhill lhc lc(lcrill rcSuhtions rcSillditlS a(bcslos rclilrval arc ntil applicnhlc b this pr()jccl <br />slrtc lhal thc nlarlc inlirrnilltrn is I igrce kr cotrrl)ly with all Cily rn(l Counly <br />of lhi\ City and Counly lo cntq upon lhc <br />l)ate: <br />nilntt <br />rntl nulh0ri/c <br />BUILDING. INSPECTOR RECORD <br />Cilil icr