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BUILDING. INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG COMMENTS OWNER BUILI)ER DI]LCARATION <br />IhcrcbyafflrnundcrpcnxltyofpcrjurythatIanrexcmilfil)rnthcContrack)rs l,iccnscInwlorthelbllowinSrcuson(Scc.7l).]1.5 <br />llusincss iln(l Prolassaill Codc): Any Cily or County which rcquircs il Nrnril lo coilslrucl. ullcr. inrprove, dcrxrlish or rcpair ant <br />slruclure.pri(trbits issuancc.alsorcquircslhcapplicanllirrsuchJrcrnrilk)lllcrsi8ncdstrlcnEnl Ihxlhcorshcislicctrscd pursulnl <br />k) thc p()visions of thc Conlrrctff's l-iccnscd ljw (Chaptcr 9. Corrrnrencing wilh Scclion 7(Xx) ol Divisi(,n 3 of thc Busincss and <br />npplicantlbrilpcrDlitsubjcctsthc npplicanlk)acivilpcnaltyofnolnx)rclhrnllvchundrcdtlollars($50O). . <br />_1. as owncr of lhe proFErty. or my cmpl()yccs wilh waScs as lhcir slc compcnsali()n. will do thc work and tha sttu1uc is nol <br />intcndcd orolli:rcdftrrsalc(Sm.T0l4.BusincssandProftssionsCode:ThcContraclor'sLiccnseLawdocsnotapplyk)anowncrof <br />lhc pn)pcny who builds or improvcs thcm)n. aftl who d(rcs such work hitrttclfor hcrsclfor through his or hcr own cmpl()yecs. <br />providcdlhatsuch inrprolcrrcntsarcnolitilendcdoroffcredforsalc.ll.ltrqcvcr.thcbuiklingorirlprovcrrcntissldwithinonc}ltr <br />ofcotrrplclion. thr Owncr Buildcr will havc thc burdcn ofproving that Ir or she did rDl build or irnprove thc pmpedy li)r thc purF)$ of <br />salc). <br />_1. as (nvncr of lhe propcrly. am cxclusivcly conlractirtS wilh liccnscd conlrilck)r\ lo con\lrucl tlE p()iccl (Scc. 7().l4. Burirrcrs <br />and lhrli:ssi<ilCodc:'[heConlrack)r'sLiccnscLawdocsn(ilrpplylornowncrofpropcilywhohuildsorinlprovesthcrcon. <br />and who contrlcts lbr such proi.cl\ with a ('orxrack,(s) liccnscd pursuanl to lhe (i)nlrack)r's l,icensc l-aw). <br />-lan|cxcnI)tundcrscction-.B'&P'c.lbrthisrcason,Dale: Owner: <br />SQBTEBLQEIfINTAIIAN <br />ITECI.ABAIIQN <br />I hfy affirrn undcr pcnrlty of pcrjury onc of thc folk,wing dcclarulions: <br />rQhuvc rmd will roinrain a Cenificutc of Conscnt to Sclf'lnsurc f(rr workcrs' conrpcnsation, as provided for by Scclion 37(n of thc <br />Lrbor Codc. f(tr thc pcrformncc oflhc work for which lhc pcrmit is issucd. <br />/haucundwill rnaintrinworkcr\'compcnsationinsurancc.as rcquircdbyScction3T0OoflhctnborCodc.forthepcrformanccof <br />lhc work for which this pcrmit is issucd. My workcrs' colpcnsalion insurancc canicr and lmlicy numbcr arc:?-vt iol.- <br />Policy tio I acl-zt- zoza <br />lfccnily rhar in lhc pcrlbrtruncc o[ the work lbr which this J,crmit is issucd. I shrlt nol cil]lroy any pcrson in any nilnncr <br />s() as to hcconlc suhjccl h thc workcrs conrpcnsrti(m laws ofCflliti)mia. flnd agrcc lhat if I should hcconrc suhjcct rc truu <br />workcrs' conrpcnsrlion provisions of Scclir)n 17fi) of lhc tlbor Codc. I shall. lbnhwilh comply wilh lhos pro!isbns. <br />WARNING: Failurc b scurc w(,rkcrs'compcnsalk)n covcruSc is uillnwful. and shall subjcct an crrpkrycr k) oiminrl pcnnllics aild <br />civil fincs up to onc hundrcd lhousand <br />Scctbn .1076 ollhc tntnr Gxlc. inlercst <br />tl,,llrr s 00.{D0). iil addili(,n Io lhc cosl of rs providcd lirr thc <br />I llcrcbv nl llflI un(lcr lrilnhy {)l Icr iur y lhxl I ur(lcr pft)visi()n Chnptcr I (comnEncitrg wilh Scction 7(Xx)) ol Divisio0 .l <br />ol lhc Ilusilcss and I'()l'cssi(rtrs Codc. and my in lbll li'rcc an(l cllcct. <br />l.iccilsc Nunrbcr:37 c>Ao 1 <br />-L2- <br />I Ilcrhy nllhnurxlcr ltnrllyr)l pcr.iory thcrc is a conslruction lcnding agcncy for the pcrlbrnlilncc ofthc work for which this frcnnit is <br />issed (Scc. 3097. Civ. C.). <br />kndcr's Nare: <br />[.ndcr'q Address. <br />APPLICANT DIiCLARATION <br />I hmhy allinr) undcr pcnalty ol pcrjury orlc of thc li)llowing dcclilrdl ions: <br />IJcna)lition Pcrmils-Asbcslos Notificalior l:cdcral RcSulalions ('fillc 40. Parl6) <br />Rcquircd Lxttcr of Notilicrti(ilr <br />_l ccnily that thc ltdcral rcgulalions rcgilding asbcslos rcrrovalarc nol applicablc to Ihis pro.iccl. <br />y't ."rtlty ttr"r t trur"this applicatbn ard slatc lhal lhc nk)vc inl'ornrali(n is coficcl. I ilErcr h comply with all City rnd County <br />or(lirunccs rcldting k) building corNtnrcti(nl. and hcreby aurhorizc rcprcscnhlivcs of this Cily nrld Ci)unty lo cntcr upon lhc <br />atxrvc <br />Apl)licnnl (,r <br />Pernil@ <br />Strtc <br />for irspectidl <br />,,,*,-O-l:Z? -2oZa <br />Set Backs <br />Forms/Steel/Holdowns <br />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 />Drvwall <br />Ext./lnt. Lath <br />Brown Coat <br />[t/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif. <br />I .r I <br />F!NAL .)1611.0 9k1Y)r L*W <br />Certificate of Occupancy I I <br />Notes, Remarks, Etc. <br />a{)rn <br />L_l \R <br />( <br />4 I <br />< <br />(N <br />,,,,"Q/-22- ?-d <br />l)s1c