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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/S!G.COMMENTS O1VNER BUII,DER DEI,CARAI'ION <br />Ihcrchyatl]rmuntlcrpcnaltyofpcrjurylhdlI!mcxcnlptfromthcContrrckr^ Liccnsel-awlbrthclollowingrca&rn(Scc.70-11.5 <br />lJusincss and Proltssion Codc): Any Cily or Counly which rcquircs fl pcrilril Io construcl. rllcr. inrprove. dctrx)lish or rcprir iliy <br />structurc.priork)its issuancc.alsorcquirc\thcdpplicanllirrs{chff,rililk)lilcrsigne(lslatcmcnt lhrthcorshcisliccnscd pursuanl <br />lo lhc pm|isi(nrs ol'lhc Coillrrct)r's l,iccnscd liw (Challcr 9. Conrnrcncitrg uilh Sccliol 7(XX) ofDivision J ol lhe Busincss and <br />ProlcsskrnsC(,dc){)rthnthcorshciscxcnlfllhcrcfi(,mandthcbisisli)rlhcrllcgcdexcmption. Anyvir)litioiofSectionT0-3l.5hyuny <br />rpplicilnllbrnpcrmitsuh_icctsthe applicanlk)rcivilpenilllyolnolrnorclhrnfivchuil(lreddollars($5(n). <br />_1. ils owncr of thc pr()lrcrty. or nry cnrpk)yccs with wagcs as lhcir \olc conrpcnsalion. willdo thc work and the slruduc is not <br />intcndcd orollarfllforslc(Se.To.l4.Busincss0ndProfessionsCodc:ThcContract()r'{LiccnscLlq'docsnotapplytoanoNncrof <br />lhc lxrprrly who huikls rtr in{rovcs lhcrm[. aild who (l(rcs such wolk hinrsclfor hcrsclfor thrrugh his or hcr own cmpk)yccs. <br />profidcdlhrtsuch inrpro\cilrnlsaren(niilcndcdorollerc(lforsnb.ll.howevcr.lhcbuiklilgorimprotcrrcntissoklwithinorcltar <br />ofconplction. lhc Owncr lluildcr will hnvc Ih( burdcn ol proving lhrt ht or shc dirl ilol buikl or irrprove th prefEyty lor lhc furynsc of <br />srlc) <br />_1. ils owncr of lhc pr()pcrly. am cxclusivcly contrrcling wilh li(cn\c(l conh'acl()rs Io colstrucl lhc prejcct (Scc. 704.1. Busincss <br />antl [\rlelssixrCodc:-IhcCi)ntraalor'sLiccnsel,aw(k)csnolapplyloanowncrol'prcltrlywhohuiklsorinrprovcsthcrcon. <br />and who c(rnlhcls for such pr()jccts wilh a Corilrlclor(s) liccnscd pursurnl lo thc Conlrack)r's l,icensc Law). <br />-lillilciclnptundcrsccli()n-.B,&P'C.l()rthisrcason,l)alr ()*ner <br />\Y0RKI.]RS' C0I\I PIiNS,\'II0N <br />I'ECI,ARAl'I()N <br />I hcrchy xllinnuldcr pcruhyof Itrjuryoncof thc folkrwing dcclarrtions: <br />_l havc and will rnaintrin a Ccnificalc ofConscnl k) Sell:lnsurc li)r workcrs coilrpeilsfltion. ils providcd for by Scction 3700 ofthc <br />latxrr Codc. ltrr thc pcrlhrnBncc ol lhe work for which lhc pcrntit is i\suc(|. <br />thc w(rk Ii)r which lhis pcrnlit is issucd. My workcrs' cotrrl)cnsation in\urrncc caf,icr and nolicy numhcr ruc: <br />Policv Number: Exnircs: <br />_l certily lhat in thc pcrfornuncc of lhc work for which lhis lcrmit is isslcd. I shall not ctrlpby aily Nrson in xny manilcr <br />so x\ lo bccoilr suhjcct lo lhc workcrs'coillpcnsalidl laws ofCnlilbrria. nnd agrcc thrl il l should bccotrlc suhjcct (o thc <br />workcrs' conrpensxtion provisions of Section -17(x) of thc Lilti)r Codc. I shall. li)nhwilh conrply with thosc pmvisions. <br />WARNINCT l;ailurc n) scurc workcrs'compcnsalion covcragc is unlawlul. rnd shlll subjcct an enrploycr to qiminal fEnaltics and <br />civil lincs ulr lo ()nc hrrn(lrLal th(trrsilxl d(,llxrs (Sl(I).0{)0). in rd(lilior to thc c()sl (il It)r lhc <br />I hcrcby allirri undcr pcilalty of p(rjury lhat I am licensd utrdcr provi\bn ol Chilptcr 9 (coililrncilg with Scctioo 700{}) of Divisio .1 <br />of Ihc Busincss and Prolcssions Codc. u(l my liccn\c is in full lorcc and cflccl. <br />l.iccn\e ,/)a, <br />Dsle: /)3 q contracto., (' <br />C(INS]'RUCTI(IN LENDING AGENCY <br />I hcrchy rlfirn undcr pnalty of pcrjury thal thcrc is a conslrucli(nr lcnding agcncy for thc pcrformance oflhc work for which lhis fErmit is <br />issucd (Scc. 3097. Civ. C.). <br />Lcr(lcr's Nanrc: <br />[f,n(lcr's nddress: _ <br />APPLICAN'I' DECLARATION <br />I hcrchy ullir-nr rndcr pcnnlty oI pcriury oilc of thc li)llowinS dcchralions: <br />Dctrx)lilion Pcrnlits-Ashcstos Notification Fcderrl Rcguhtions ( l itlc 40, t'trI6) <br />-Rcquircd <br />Irllcr ol Nolilicalion <br />_l ccrlify thilt thc fc(lcral rcgulillioDs regilrding ashcslo\ rcrn(lvalrre n(n uff licahlc l(, lhis projcct. <br />ati)vc nEnlioncd lropcny li)r inspcclion <br />Appliconl or Agent Signtrturel <br />I'rrnrilce Dnnrc (priDl ): <br />4_"/ts/ rq <br />Set Backs i <br />Forms/Steel/Holdowns ql ,ol/7 trH.?/a{ <br />Erection Pads lt <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVl nsulation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />ft/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />FINAL lo/3o/ tt Jt416 lru s t#ra) <br />Certificate of Occupancy t <br />Notes, Remarks, Etc <br />aJ &/( <br />I <br />l)alt: <br />"4