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BUILDING. INSPECTOR RECORD t <br />SITE.WORK DATE ID/S!G.COMMENTS <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVl 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 />Engineer Final Report <br />Flood Zone Certif. <br />FINAL /O -2?-/7 Gr*/ q ? <br />Certif icate of Occupancy <br />Notes Remarks Etc. <br />) <br />OWNERBUILDERDELCARATION ,\ <br />IhcrchyallirmundcrpcnallyofpcrjurythatIamcxcmplliomthcConlrack)rs Liccnscl-awlbrthclbllowingrcason(Scc.?tl]l.5 <br />Busincss {nd Pr()lcssi()n C(xlc): Any Cily or County which rcquircs a ;trmil l(} c(}nslrucl. altcr. improvc, dcm)lish or rcpair any <br />struclurc.pri()rloits issuancc,alsorequircslhcapplicanlli)rsuchlErnlitk)liledsigncdstatcmnt thathcorshcislicensed pursuanl <br />k) thc provisions of lhc Contracbr's Liccnscd Law (Chaplcr 9, Commcncirrg with Scclion 7()()0 ol Division .1 of lhc Busincss and <br />ProltsstonsC()dc)orthrlhcorsheisexemptthcrcfiomandlhcbusisli)r(hcallcgcdcxcnrptiql. AnyviolalionofScctionT0-ll.5hyany <br />applicanl lirr a t--rmit subjccts the applicrnl k) a civil fcnaltyol not fr)rc lhln livc hundrcd dollars (5500). <br />_1. as owncr of I hc prcFrcrty. or nry c mployccr wil h wapc\ as thcir solc conlltnsal i(]n, will do tlrc work &rl the stntluN is fril <br />it)lcndcd orolltrcdti)rs{lc(Scc.T044,BusirrcssandPtotcssitxrsCodc:'lhcContraclor'sl,icenscLawdoesnolapplyl(l{nowncrol- <br />thcpnlfrcny wkrhuildsorimprovcstlErqrr.drlwh)d(Essuchworkhimscll'orhersclforthntughhisorhcrowncmployccs, <br />provirlcd thal such improvcftnts uc not irlcndcd orolltrcd li)r srle. 11. howcvcr. thc buildirrg or improvcmnt is s)ld within onc ycil <br />ol complct()n, thc Owncr Buillcr will havc th! burdcn ol lroving th{l hc or shc did not huill or inrprovc thc pn)lEfly lbr thc purFx)* (][ <br />salc). <br />_1. as owncr of thc propcrty, !m cxclusivcly crnilrncl ing wilh liccnsed contract)rs k) construcl thc pfi)jcct (Scc. 7044. Busincss <br />and PNfessiln Codc: The Conlractor's [,i(cnsc Law docs nol apfly k) an owncr ol prol^.^rly who huilds or improvcs thcrcon. <br />and who conlracls i)r such projccts wilh a Contrac(or(s) liccnscd pnrsuant k) thc Conlrachr's Liccnsc [rw). <br />_l am excnlpt undcr Scction-. B. & P.C. ti)r lhis rcasul. <br />Date:- <br />WORKI:IiS' ('()NIPENSATION <br />t)ECl,AR Ll lON <br />lhcrt'hyal'l'irrrrndcrr-niltyolpcrjuryoncr>ithclirlhrwingrlcclarationr: <br />_l havc akl will mintain a Ccdillcatc of Conscnt k) Sell:lnsurc li)r workcrs'conrlrcnsalion. as pnlvidcd li)r by Sccli(rn -17(U of lhc <br />Lakrr Crxlc, lirr thc pcrlin'mancc of lhc work lbr which thc ltrmil is issucd. <br />_lhavcantlwillnrrintiinworkcrs compcnsali(nrinsurancc.as rcquircdbySccti()n-l7U)ofthcLahorC()dc,tilrlhcpcrlbrilranccol' <br />thc work li,r which this pcrnlit rs issucd. My workers eomltnsllion insurancc cmicr uxl Jxrlicy rrunrhcr uc: <br />Pr)licy Nunrhcr: Eipircs: <br />%.n'rry ,nr, ir thc I-.-rlirrnrrncc of thc work ti)r which this l^-rmit is i\sucd, I shall not cmphv any person in any mannt'r <br />- so as kr hceomc suhjcct t, thc w)rkcrs'conlpcnsalion laws ol'Calili)rnir. rnd agrcc thlt if I sh()uld bccomc suhjcct k) thc <br />workcrs'compensrti()nprovist)nsolScclil)n.l7U)ollhcL{h)rC(xlc.lshall.li)dhwilhconrplywilhllx)E <br />WARNIN(;: F{ilurc k) sccurc workcrs conrpcnsalx)n covcragc rs unhwlitl. rnd \hall suhjecl dn criminrl frcndltics {nd <br />civil lines np k) (nle hundrcd lhou\and dollar\ (SI00,UX)). in cost ol'as providcd lbr thc <br />S('ctx),r -1076 oi thc I-ahn Cltrlc. iilcr!'sl rild Itc\. <br />Y"", ,l-/t l/,/ <br />l,l!( 1,,\R,\ I l()\ <br />I hcrchy allirm undcr pcnrlty oi pcrjury thxt I rm liccnscd unJcr pr)visi(rr i <br />ol thc Busincss and Prol-essrrns Codc, and nry liccnsc is in lill torcc ind <br />(conlmncing with Scclion 70(x)) of Division J <br />-icctr\c d Nunrht'r:1o Ltll <br />I <br />. CONSTRU(:TION LENI)ING AGENCY <br />issucd (Sec. -1097. Civ. C.). <br />Irnd!'r's Namc: <br />I..n,ltr'\ Ad,h?(\l <br />APPLICANT DECLARATION <br />I hcnby allimr under pcnalty of perjury onc of lhc tbllowing dcclrrrtions: <br />Dcm)Ilon Pcrmils-Aslrcsk)s Nolilication Fcdcral RcSulal()ns ('l illc 40. Pa(6) <br />-Rcquircd <br />tf, ltcr ol N({ilicalion <br />with all Cily rnd Counly <br />and County to cntcr ulxu the <br />alx)v. nrcnti()ncd p()pcn], li)r ilspccli()n purf)scs. <br />!ipplicant or Agent <br />l.-Pcnnitce nanrc (prirl <br />lol rpplicablc x) this pr)jcct. <br />Cnricr