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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BTJILI)I]R DEI,CARATION <br />I hcrchy alfirnr ntrdcr pentlty of pcrjury lhill I am excrnpt lioilr lhc (inilrack)rs Liccnsc Larv for thc folk:wing rcrson (Scc.70-31.5 <br />Buciilc\s tnd Proli'(sion Code)i Any City or County which rcquires il FrDril lo con\lrucl. allcr. ilu'ovc. dcnDlish or rcflir any <br />lo thc l)trvisions ol thc Contrnck)r's Liccnscd l;rw (Chaptcr 9. Conlrcrcing with Seclion 7(X)0 ol Division.l oflhc Busincss and <br />Prolt\\ionsCode)orlhatlEorshciscxcmilthcrclromandlhehxsi\fortht'allcgcdcxcrtption. AtryviolalionolSecltttrT0.ll.5hyaiy <br />applictnlli,rrpcrnritsubjcctsthc rpplicilnlhacivilpcnrllyof[olnx)rcthanl'ivchun(lrcd&)llrrs($5(x)). <br />_1. ils oNncr of lhc profrf,y. or trly cmpk)yccs silh wagc\ as tlNir solc c(nnlEnsxlion. willdo lhc work ilnd thc slftturc is not <br />intcntlcd oroflcrcdlirrsalc(Src.7(Il4.BusincssandProltssions(l{lc:'lhcConlruclor'sl,iccnsclnwdocsnotapplytoxnowrcrof <br />thc pn)lrcf,y who tililds or inpro\c\ thcctrl. and who dms ruch work hinr\cll or hcr\ell or lhrou8h his or hcr own cnrpk)yccs. <br />provi(lcdthtlsuch inlprovcilrntsdrcnotinlcndcdorofltrctlfirrsalc.lf.hrtwcvcr.lhchuildingorhrrprovcnrcntiss()ldwilhinoncyctr <br />ofcomflcli(nr. thc Osncr Buildcr will ha\r thc burdcn ofproving thal lrc or shc ditl Dol buikl or imlxrw lhe prcpcdy for tlt puqx)$ of <br />salc)- <br />_1. rs ou'ncr of lhc propcrty. am cxclu\ivclv conlrnctilrg wilh liccn\cd conlrrclors lo coil\lrucl lhc projccl (Scc. 7(H4. Bu\incs\ <br />and PnrtLssinCodc:'lhcContrxctor'sLiccnsc[-awdocsnolapplytoilnowncrofpropcrlyshohuikls()rinrplovcslhcrcon. <br />and sho c(nilrrcls lbr such pr(iccls wilh a Corilrackn(s) liccnscd pursurnt lo lhc CoDlrxcbr's l-icensc Law). <br />lrilrc\rlrl)tlrtr(lcrSe.liorr .li&l'(.1()rllli\rcist)rr <br />l)nle ()$nrr: <br />WORKFRS' CONIPI'NSA'I'ION <br />DECLARATION <br />l hcrchy allirnlun(lcr pcnallyoIpcriuryonc of thc lolk)wirtg declnralion\: <br />_lhavcuxlwillnrninluiililCcrriljcatcofConscntk)Sclf-lnsurclirrw()rkcrs'coilrpcnsalion.as providcdforhyScclion.lT(X)oflhc <br />Labor Codc. for the pcrfortrrancc of lhc work for which thc pcrtnil is issuc(|. <br />fllhrvcanrlwillnainlainworkcrs'conrpcn\arioninsurrncc,as rcquircdhyScctt)n.17(x)oflhclnborCodc.li)rrhepcrlbrnrilnccof <br />lhc work for which lhis pcnril is issrcd. My workcrs' cotrrpcnsalion irsurancc carricr atr(l policy rlumher nrc: <br />vl <br />e.ri.yNu,.t",,4205935 -I4 e,pi,".,<,t zl ?l;2 6 <br />_l ccllity rhtl in rhc lrcrli)rnuncc r)l thc Nork for shich lhis pcrnlit i\ issucd. I shall nol cnlpk)y any pcrson in any rtanncr <br />so ilstotEconrcsubjccllothcworkcrs'cotrlpcnsrli(mlcwsolCalili)rnia.ilil(lagrcclhaliflshouklhecontsubjcctlolhc <br />workcrs'coillpcn$tionprovisionsol'ScclionlT(X)ofthcl-ahrrCotlc.lshall.fitrlhNithconrplywilhlhoscprovirions- <br />WARNIN(;: I:ailurc to $'curc workers'conrlrnsation covcraSc is unlawlirl. an(l shall suh.iccl in cnrpk)ycr k) criminal fEnallic\ !n(l <br />Scction -1076 o[ thc [;rtr)r (l)dc. inlcrcst rn(l rthnty s lccs. <br />oare:!-'2-:?t. lZatc, nrr,,."*' Q&qrl--(e <br />LICENSED (ONTRAC'I'OR <br />IIECI.ABAIIQN <br />I hcrchy flllirnr uDdcr pcnalty of pcrjury thnt I am liccnsd undcr provision of Chrptcr 9 (conrmncing wilh Scclion 70(X)) of Division 3 <br />of thc Bnsincss rnd Profcssions Codc. ilnd rny liccnsc i\ in full litrcc akl cfltcl. <br />l.irettsc Nurrl)cr:IozsocJ <br />Dare: t hq I -Lo Lo Conlrnclor:G-t+ Qer-s>\b<>vr <br />CONSTRUCTION LENDINC ACENCY <br />issucd (Scc. l{)97. Civ. C. ). <br />l.cnJcr's Nrrrrc: <br />- <br />L-cndcr's n(l(lrcss: <br />APPLICANT DECLARATION <br />I trrcby allirm undcr pcnahy o, pcrjury onc of thc lollowing dcchriltions: <br />Dcrrxrlirion Pcrmits'Ashcslos Nolilicalion ftdcral Rcgulalions ('l'itlc 40, Pafl 6) <br />_Rcquircd Lcllcr of N(ililicati(rr <br />-l <br />cc!1ily thrt thc fcdcral rcguliltions rc8ilrdinE! asbcsk)s rclnoval are not applicablc 10 lhis Projcct. <br />tlQt ccniiy rhur I hilvc rcad this application trnd stalc thrt thc at$vc inlbrmrlion is corccl. I aSre k) colrply wilh nll City and County <br />ordiDxnc€s ilnd Statc l-uws rclating lo building conslruclion, and hcrcby aulhorizc rclrcscntalives ol lhis Cily and (l)unly lo cilcr upon thc <br />ahovc nEnlt)ncd propcny for inslrcction purFnses. <br />Al,plirilnl (il-,\grnl Signillilrc <br />ItcrnrilN nilnrr (pritrl):.r", cg\( 5 <br />o"r" \ lzqf?ozo <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/Vent/l nsu lation <br />Roof Sheathinq <br />Shear Wall <br />Framino <br />lnsulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Jt/lasonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Enoineer Final Report <br />Flood Zone Certif <br />//,l/ <br />F!NAL blD/z{n @/.U,f ,Y <br />Certificate of Occupancy <br />Notes, Remarks, Etc