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SITE.WORK DATE IDiSIG.COMMENTS ott'Nt.R BUil-t)uR t)lll,( ARA l l()N <br />IherehyaffinilunderpenrltyofperiurythrtIanrexenrptfromtheContract)rs l-icensel-awforthefolk)win8r€ason(Sec.70-11.5 <br />Ilu\ine(( and Profes\ion C{xle): Any City or ('rrunty uhich requires r lErnlit n) conslrucl. rller, irnnn)ra. dem)lish or renitr 3ny <br />structure.pri)rtoit\ issunnce.alsorequirestheanplicnn(forsuchpennitlrfileasignedstilterfrnt thatheorsheislicensed Pursuanl <br />[, th€ provi\ion\ of tlE Conrractor's l-icensed Law (Chnpter 9. Commencing wilh Sec(ir)n TIXX) of Division ] of the Business and <br />Itr()fes\ionsCode)orthatheor\heisexempttherefromrndlhchr\isforthexllcSedexempli()n. Anyviolatit)nofSecti(rn?0ll.5byrny <br />applicanl for a nermit suhiects the applicanl to a ci!il penahy of n()t nx)re than file hundred dollirs ($5(X)). <br />_1. as ()wner of thc proFny. or my empl()yees with sr8es rs their $h conlen{(i(n. willdo thc work and lhe stulw i\ frtr <br />iilended orofferedforsrle(S('.?(H4.Businessandltofession\Code:TheConlractor'sLicensel.awdl)esnolaPPlyhanownerof <br />th€ profEf,y sho hoilds or improves rh€E)n. and who dcs \uch wotk himrelfor her\elfor lhrouSh his or h€r own emPloyees. <br />pft)vided thflt such in!)rovemnts ile not intendd oroffered fir sale. li h)wever. tlf huikling or imnroverrnt is s)ld within one year <br />ofconrpletion. lhe Owner Buiuer will hive the borden of pn)ving thil he or sh€ dil nol huiu ()r improve tlc pmJrny frrr the purF)E of <br />sale). <br />_1. as owner of the propeny, am exclusively contracting with licensed contractors x) conslnrct the proiecl (Sec. 7044. Business <br />and Pfi)fssirnCode:TheContrack)r'iLicense[.iwdoesfiXapplyOanownerofproperlywhobuild\orinrproreslhereon. <br />rnd who contrncls for such pn)iect\ wilh a Conlroclor(s) Iicensed Pur\uant ki the Contracntr s l.icen\e Ltw). <br />-l <br />arn exefipl under Section-. B. & P.C. frrr this reason. <br />Dalr:()wtrer: <br />}VORKERS' COI\IPENSA'ITON <br />DI'CLARAl'ION <br />l h.reby rfftm un(ler penrlty of perjury one of lhe fi,lk)u'ing declrrnli(in\: <br />_l tllve mt u'ill maintain a Cenifrcale of Conrnt k) Self-lnsure f(r workers conrfEnsation. as provided for by Section l7(X) of lhe <br />Latx)r C(de, firr the performance ofthe work for which the permit i\ issue(l <br />_lhrverndwilloilintainworkers contpensationinsurrncc.as rcquire(lhySection3T(X)ofthcl,aborCo(le.fortheperfrrrnrrnceof <br />thc sr)rk for *hich lhis pcrmit is i\sued. My workers comp€n{rlion in\urance cnrrier rnd lr)licy nunrher are: <br />I rltqPolicy1/', <br />_l cenify rhar in rh€ofthe work frrr which this pernit is issued. I shall not empby '[ -s I l <br />any per$rn rn int manf,er <br />so as to hecrrrrc suhiect h the workers' compensrtion lnws o[ Califirrnir, rnd aSree thrl if I should hecotne suhiect to lhe <br />urrrkers'contpensationpr)visionsofSectir)n:17(X)oftheLrhtrC('de.lshrll,foflhsilhcomplywithlh(,sprovi\ion\. <br />WARNTNG: lrailure lo *cure workers'compensalion coverage is unlrwful. ilnd shall sohiect ril enlfkryer t) criminal pcmllies and <br />civil fine\ up to r)ne hun(lred thou\and dollars ($l(x).{fi)). in a(l(lition cost of conrpensation, rlarnager as providt(l for tlf,' <br />Sccti{)tr fecs. <br />l)tte: <br />I herehy rffinn under penrlty of p€riury lhhl I ailr Iicense(l of Chnpter 9 (commncing with Seclion 7(XX)) r)f Division -l <br />of thc llu\inc\s rnd Prol't'rsi0ns Crrlc. and my licen\c i\ in lirll lirrce antl effcct <br />Licensc <br />Dale: <br />Nunrher: <br />I herehy afllrm under Frnnlty of perjury thnl lhere is a constructi()n for the perfornrince of the work for which thir perntit is <br />issued (Sec. -1097, Civ. C.). <br />lrndeis Name: <br />Lender's Ad{lress: <br />APPLICAN'T DECLARA'I'ION <br />I hercby fllllnil under Fenahy of perjury onr of the folk)wing declarations: <br />Demlirion Permits-Ashe{tos Notificntion F.deral Regulations (Title 40. Paf,6) <br />-Required <br />Lettcr of NolifEation <br />-l <br />cef,ify rhal the federalrcgulations reStrding asberhs renx)val:rre n(il llpplicahlc to lhis Pr()iect. <br />-l <br />cenify thrt I have rer(l this npllicalion and strle in firrm{ ion is cotrc.r. I ilgre tr) conlply <br />' reue\en(atives of lhil ('ily <br />wirh all ('ity and County <br />nn(l County b enter upon lhe(mlinrncc\ and S(alr l.rw\ rulxtinA lo huikling herchy fluth)ri7!' <br />atrrve mntioned prope(y f{)r <br />Applicant or Agent Signature: <br />Itemitce nanre (printl:-+t n4 <br />*r",W <br />Set Backs <br />Forms/Steel/Holdowns -4fr v ruU u r\lD g. ) <br />Erection Pads I {git'",e4\iltG{ <br />UFER Ground r t-/,T r,6Y <br />SLAB Floor <br />SubflooriVenVlnsulation I <br />Roof Sheathing 1/3t f/ZO,t,lL ?Zt toV <br />Shear Wall P/./]il '/t ta'4 <br />Framinq <br />lnsulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />lVlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />t <br />FINAL L '/.0 Dltrflr 1,16 I <br />Certif icate of Occupancy fr U <br />Notes, Remarks, Etc. <br />BUILDING. INSPECTOR RECORD <br />tr'lev 0B-0 /-201 5 <br />(-trtrier <br />t4_Applkunt: <br />q lr+-A:JL\ --