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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenUl nsu lation <br />Roof Sheathing <br />Shear Wall <br />Framing <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 />Enoineer Final Report <br />Flood Zone Certif <br />/.\ <br />3-31JoF!NAL V.il-tcl\ <br />Certificate of Occu <br />Notes, Remarks, Etc. <br />OWNT:R BU II,DER DIiI,(]ARATIoN <br />IherebyalfirmunderpenaltyofperiurflhatIaneremptfromtheConlrack,n Licmsel.arvforthefollosingre6on(S(.7(ll.5 <br />Business and l'rofession Cocle): Any Cily or ('ounty rvhich requir$ a pqnit to conslnrct. alts. improve. demolish or repair hny <br />slruclue. prior lo ils issuance. also requirs the applicant for such fmDit lo file a signcd statmmr thal he or sh€ is licmserJ pursufnt <br />to lhe provisions of the ('ontractor's Licensed l,arv (Chapter 9. (innrncncing with Scction 7000 of Division .l of the lJusiness and <br />Profcssions Codc) or that he or she is exentpl lhoefion and lhe b6is for lhe allescd exernption. Any tiolation ofS(tioil 70.1 1.5 by .ny <br />applicant for a pennit subjects thc applicant to a civil penally ofnot more lhan five hundred dollars ($500). <br />1.6 orvneroflheproFErly.ornlyemployeBrvilhrvagsaslheirsolecornpensation,willdolheworkaildthcslnKtueisnot <br />intorded oroffcredforsle(Sc!.T044.BusinmandProlessirrnsCode:IheConlrackrr'sLicmse[-asdo6notapplytoano$'nsof <br />thepropdy rvhobuildsorirrprovathqqrn.odrvhodoesuchwofthimselforherselforlhroughhisorherorvnemployes. <br />provided that such irnprovenenls ue not intmdcd crroffsed for slc. lf. howq,6. lhe trrilding or tnprorerDmt is $ld wilhirr oile yw <br />ofconrplelion, the Clrvncr Buildq u'ill have lhe burdo ofproving that he or she did not build or inrprovc the pmpoty for the puryrs of <br />slc). <br />_ I.morvnerofthepropfly.ancrclusivclyconlractingwithliccnsedcontrackJrstoconstnrcltheprojecl(Sec.7044.UusinNs <br />md ltofushn Code: l he Conlraclor's License l,a$ dos nol apply lo an owner ofprolEny \r'ho builds or improve therann. <br />and who conlrads for silch pro.jects rvith a Contraclor(s) licmsed pursuant k) lhe (l)ntraclor's l.icense l,arv). <br />- <br />I dn exempl under Secttrr-_ <br />Dnte:()il trer: <br />WORXERS' CO[IPENSAllON <br />DECLARATION <br />I hoeby allinn unde penalty of gmjury one of thc follorving clelaratiom: , <br />-_ I have md will rnainlain a Ce(ificate ofcoLsent to Self-lnsure for works's compensation. o provided for by Setion 3700 oflhe <br />Latxrr Code. for thc petfonnance ofthe rvork for rvhich the pmnit is issued. <br />-lhaveandrvillmaintainrvorkss'cornpensalioninsurance.6 <br />requiredbySstion3T00oftheLaborCode,forthepsfonnanceof <br />lhe work for which lhis pennit is Lssued. My rvorkos' composation insurance catq ild policy numbq ile: <br />('miq: <br />Policy Numbqi -,Expires: .- <br />I cenify that in the perforrunce ofthc work for which this prmit is issued. I shall not onploy any poson in any manner <br />m astobecomcsubjellothervorkos'compensalionlawsofCalifomia.andagrethatiflshouldbecomesubj(ltolhc <br />rvorkm'composationprovisionsofSection3T00oftheLah)rCode, lshall.fonhwithcomplyrviththosprovisions. <br />WARNINC: Iailure to sure workers'compensalion colsa8e is unlarvful. ald shall subjrt m mployu to qfuninal poatiG and <br />cilil finesuploonehundrcdlhousanddollm($100.000),inadditiontothccoslofcompensation.danagescprovidedforthe <br />S(lion 1076 of the tabor Cod€. inlo6l and attomey s le6. <br />,^r., /o - ?3- Lotg oppr"^nr, I C - ---- <br />r-r <br />DECLARATION <br />I hrcby affirm unde pmalty of pqjury that I an licmsed undo provision ofChapts 9 (commencing wilh Sction 7000) ofl)ivision l <br />of the lJusiness and Profssiom Code. md mv license is in full force anl elfecl <br />[J. & l'.C. for lhis reasotr. <br />Liccnsc ('lass: <br />l-crrdcr's Adtficss: <br />l.icensc Numtrcr: <br />oate, /o' 23' ?2L1 .on,."uo.,(a a <br />lhcrebyal1.irmunrJopmul.,ofo".i.,o,ho.,hffiq-firnnanceofthcwor.kforwhichlhisporilitis <br />issued (Se. 1097. Civ. C.). <br />Lenrler's Narne: _ <br />APPLICANT DtrCLAIIA'I'ION <br />I horrry- aflinn under penally oI pejury onc of the follorving delarations: <br />Dernolition Permils-Asbestos Nolificatbn F'ederal Rcgulalt)ns ( l itlc 40, Pat6) <br />, Requiredl-dtqofNotification <br />I ccl1il-y thnl lhc lt(lcral rcgulalions rcgruding ashcstos rcrrrrval rrc nol .pplicnl)lc lo lhis proiect. <br />atrevc nrentioncd propmy lor irrspection puqress. <br />ApplicsntorAgentsignarure: L <br />2 - <br />OL,'s-ku\ <br />oare: lo Z3'Zotl <br />l'ernritce tramc (pritrl):