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BUILDING. INSPECTOR RECORD <br />I hcrehy altirnr undcr lEnalty ol pcrjury thrt I anr cxcnrpt lroDr thc Contraclors Liecnsc [rw li)r lhc followirut rcason (Scc.?o]1.5 <br />llusiDcss and l,roltssion Codc): Any Cily or County which rcquircs a lErnril lo conslruct. allcr. improvc. dcmolish or rcpair dny <br />slnrcturc.prk)rk)its issuancc.al$orcquucslhcapplicantfi)rsuch[rrmillolilcasiSncdslatcmnl lhnlhcorshcisliccn*d lursudnl <br />lo lhc provisions of tlr Conlraek)r's l-iccnscd l-aw (Chapter 9, Comnrcncing wilh Scel()n 7(XXJ ol Divisirrn .1 of lhc Busin.ss an(l <br />Ptr)ltssionsCodc)orthnthcorshciscxcDrptthcrcfiomrndthchrsisli)rlhcallcgcdcxcmption. AnyviohtionofScctionT0-ll.5hyany <br />applicantli,rapcrnritsubjcctsthc applicanlk)acivilpcndltyolnotoxrrcthanfivchundrcddollars(5500). <br />_1. as owncr ol'the pn)fErty, or my cnrpl()yccs with wagcs as llEir solc comfcnsili(rl. willdo tlE work dd thc strutrrc is not <br />iilcnded orollcrcdli)rsrlc(Se.7044.BurincssandProltssionsC(xlc: IhcC(nilhck)r'sl-iccnscllwdr)csnotapplyk)tnowncrof <br />thcpR)fEt1y whohuildsorinlFovcsthcrc)n,dklwhod(rcsruchworkhimsclforhcrscllorthff)ushhisorhcrowncmJ,loyccs. <br />providcd that such imp()vcn*nts rc fil itilcndcd orolltrcd iirr salc. Il. lxrwcvcr, thc huiklirrg or improvcnrnt is s)kl wilhn onc ycil <br />ol c()mplcti()n, Ihc Owncr Buildcr will havc thc burdcn of J,roving tlut Irc or shc did not huild or itnprove tlrc pmFrny fi)r the purJx)sc ()f <br />sn[r. <br />_1, as owncr ol'thc p()pcrty. rm cxclusivcly contractirtr with liccnsed eonlractors k) c(,nslruc( lhc p()jcct (Scc. 7044, Ilusincs\ <br />ul Pn)lcssDnCodc:'I-hcConlfuelor'sl,iccnsc[,awdocsnotapplytoanowncrofpropcrtywhobnildsorinrprovcslhcrcon. <br />and who c(,nlrtcts ti,r such projccts wilh a Corilrack,r(s) liccilscd pursuant k) thc Contrack)r's l-iccnsc Law). <br />lVORKERS' CONIPENSATION <br />DECLARATION <br />I hcrchy all irm undcr pcnalty ol I--rjury (nrc of thc li)ll()wir)e dcelxratiotrsi <br />_lhavcmdwill mahtrinaCcrlilicatcofConscntk)SclLlnsnrctorworkcrs compcnsnlion.as providcdtbrbySccliur.lT00ofthc <br />Irtx)r C(xlc. ti)r lhc Frli)rtrlanec ol' I hc work fbr which thc pcmril Lc issucil. <br />_lhavcandwillmainlai,lworkcrs'conrpcnsalioninsurancc.as rcquircdhyScclfi)n.l7U)oflhcLaborCodc,li)rthcpcrtilrnuDccof <br />thc work li)r whieh this pcrmit is rrsued. My workcrs' cofirpcnsaliur irrsurancc cafiicr uxl ftlicy rrrmlrcr uc: <br />any in any oranncr <br />\i, rs to hc(('nr \uhjcut to thc workcrs'contpcn\xltr)n hw\ (,1 C)lt'rnra, <br />wd*cr\' !rrnp('n\atknt nr)vlsx,n\ ol Scclion .17(Xl rrl lhc Irhl (iilc. I , <br />IVARNIN(;: Frilurc k) sccurc w(nkcrs'rompcn\nlion (ovartgc ts <br />civil lincs up to rnrc hundrcd lhrxrsand dollars 100.(XX)). in r.].liti({r <br />Scction .1076 ol Codc, <br />I hcrcby allirm undcr pcnally ol pcrjury <br />alrcc thal il I should 6uhjcct lo I <br />ti)dhwith comply with <br />rnd shall subjccl in lcnah,cs ild <br />ol thc llusincss and Prolcssiurs Codc. and nry liecnsc is in lirll li)rcc dtl cltcct. <br />as providcd for the <br />DECI,ARATION <br />undcr provisi(n of Chrptcr 9 (comnrncilrg with Scct()n 7Ux)) of Drvistr)n J <br />ol thc work tbr which lhis Frmil i$ <br />lhc cosl of <br />I anl <br />I-iccnsc Class:-Liccnsc Numbcr: <br />l)ate:- Contrsctor: <br />Ang.*r.rnrn rrnr,n" n,rrn., <br />IhcrcbyallirmundcrFnaltyofpcrJurylhallt;7q-..*m.,,,l.'.l',t"8*ytbrlhcpcrli,mancc <br />ilxilliii";lill" ''' P--l 4/cr F <br />I-cndcr's Addrcsl <br />DCnl x,Icd <br />ApplicsDt <br />s- <br />lo lhis Uojcct. <br />S,nfi ltnarcta <br />421o2APPLICAN't DECLARATION <br />I lrcrcby {llinn un.lcr lrcnally o[ I^-rury onc of thc li)llowin8 i.lcclarati(]ns: <br />[)cfr)Il(rn Pernl(s-Ashcslos Notificdlion Fe'lcral Rcgulalions ('l itlc 40, Pan6) <br />-Rcquucd <br />lJllcr ol Nolificali)n <br />tlut regulations rcgudinS <br />1 <br />with all City nnd C(trrnty <br />uF)n thc <br />SITE-WORK DATE ID/SIG.COMMENTS <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 Sheathino <br />Shear Wall <br />Framinq <br />lnsulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />[Vlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />,iI/,.? <br />FINAL b'll'4)/4)u.{111 T4Alffi <br />Certificate of Occupancy <br />Notes, Remarks, Etc <br />II'rrtrrilcc nantc <br />lhc <br />lirr x)n fuqx)\cs. <br />ashcstrs rcilx)vnl <br />is coftcct. I <br />and (i)unly lr) <br />c-\ <br />-l <br />am c\cmpt unrjer Sccton-. B. & P.C. for lhis reason. <br />Dslc <br />- <br />Oener <br />a