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IhcrchyallirnrundcrpcnrlryofpciurythatIamc\cmptli)mthcContruek)rs Liccnsc[-awlirrrhclblkrwirigrcas)n(Scc.70-11.5 <br />Busilcss nnd Prolassion C(xlc): Any City or Connly which rcquircs a lL.*rnlil t() conslnrct, allcr, improvc. dcm()lish or rq)air uy <br />struclurc.p[]rloit\ issrancc,!l$rcquircslhcapplieanlli)rsuchl-*rfiilk)lilcasigncdstalcnrnl thalhcorshcisliccnrcd pursuanl <br />b thc provisir)ns ol thc Contraclor's l-iccnscd Law (Chaptcr 9, Comntncing wilh Scciion 7000 of Divisi(u li of lh" Busurcss and <br />Pro,tssions(ilde)orthallEorshcisexcnllnthcrclilrnandthchdsisli)rth(-rllc8cdcxcmplion. AnyviolalionolScctionT0-ll.5hyany <br />rpplicnnt li)r a Frnrit suhjects thc rpplicrnt k) d civil pcnaltyofnot ntlrc lhdn fivc hundrcrl dollars (5500). <br />_1. rs owncr of thc proFEny. or my cnlployccs with wagcs as lltir sole conlFEnrat ir)n. will do thc work url the s(mtuc r\ frn <br />iilenrjcd oroll'cred lirr salc 1Scc.7(X4. Business nnd Prolcssions Codcr Thc Cinilraclor's Liccnsc l-aw docs nol apply t) rn owncr oi <br />the F)Frcf,y wlx) hililds or inrlF)vcs thcru\)n. :ukl w[K) d(rcs such wo* himscll or hersclfor lhff)ugh his or hcr own cmpl()yccs. <br />providcd th{l such improvcrRnts rc nol ntcndcd orotlcrcd l'or salc. lt. howcvcr, thc huilling or improvcnEn( is solJ within onc y('il <br />ofcomplcti(nr. thc Owncr Ruilder will havc tlrc hurdcn ol pR)vir8 lhal hc or shc did not huild or improvc thc pR)fEny ti)r thc puryxrsof <br />sah). <br />_1. i\ owncr ol lhc l)ropcny. rnr c\clusivcly conlrdcling with lircnscd conlraeors k) construct llE projcct (Scc. 70214, Busincss <br />tnd Pn)lbssi[Codc:_[hcConlrack)r'sl,iccnscl,trwdocsn(ilapplyl)anowncrolpropcrlywhobuildsorimprovcsthcrcon. <br />and who contmcts fi)r such pr)jccts wilh a Conlrnalo(s) liccnscd pursuanl k) lhc Conlrack)r's l-iccnsc Jiw). <br />_l atrr cxctrrpt unrlcr Sccl U. & P.C. li)r lhis rcisoD. <br />}VORKERS' COI\IPENSATION <br />DECl,ARATION <br />I h.r!-hy al'l irnr undcr pcnillly ol pcrjury onc ol't hc li)llowirg (lcchral ions: <br />_l hrvc and will nlaintrm a Ccf,ilicutc ol Conscnt k) Scll:lnsnrc fi)r workcrs conlpcnsalion, as providcd li)r hy Sccti()n .17U) ol lhc <br />hlx)r (ixlc, li)r thc Frli)rnrancc ol lhc work li)r which thc pcmril i$ issucd. <br />_l h{vc and will nlain(ain workcrs comlrcnsatt)n insurdncc, ns rcquircd hy Scction 37Ul oftlt l.ahor Cl)de, li)r thc pcrli)rmancc ol' <br />lhc work lor which lhis pcrmit is issucd. My workcrs eonrlcnsali()n insurancc cafricr uxl Fllicy numbcr sc: <br />Policy Nu :\pirc\: <br />_l ccdif y thnt iD thc l^-rli)rnlnnrc ol'lhc work lbr which llris pcrnril is issucd. I shall nol crnpl()y any F-rson irr any mn0ncr <br />\o rs lo h(conr suhjcct k) lhr w()rkcrs'compenration laws of('llili)mia. {nJ aprcc thrt if I shoukl auconrc subjcct lo lhc <br />workcrs'corrpcn(rri(DprovisionsofScctirrr.lT(l0ol(hcl-ahnCodc,lshall.lbnhwilhcomplywilhthoscprovi\ions. <br />IVARNING: l-ailurc'to sccurc workcrs'c()nrl^-nralion covcrrgc is unlawlul. and \hall suhjcct rn cnTkrycr t) crimiral fEnrllics and <br />Scclxrn J07(, ol lhc Lxhr'(i)dc. irrlcrc( lDd xlftnncy s lccs.fitt* <br />I-i(cnsc Cla\c:-Ltccnsc Nunrhcr: <br />Applient <br />t-t( ENsEr) coN'rRA('l oR <br />DU(-1,ARA'ilON <br />I hcrchy ailirm unrJcr penalty of pcrjury thrt I am liccn*d\ndcr p()vist)n of Chaplcr 9 (comnrcncine with Scc(ion 7(X)0) of Division -l <br />of thc Busincss dnd Proltssions Code, dd nly liccnsc is in llll forcc.ukl cllcct. <br />'ot)u( <br />I)ale n L //- <br />CONSTRUCTION LENDING A(:ENCY <br />Ihcrl'hy{llir[]undcrlEniltyof l-*rjuryth{tthcrcisrcon\trucl()nlcnJingaScncyli)rlhcpcrli)rmancc(}llhcworktbrwhichthi\FnrmitLs <br />issuL\l tScc. 1l)()7. Crv (.). <br />[-cnder's Nltrrc: <br />knrlcr's Ad,lrcs(: <br />APPI,ICANT DET]LARATION <br />I hcre-by allirm untlcr 1^-ndlly ol I--rjury onc of lhc li)llowinE Jcclnral x)[s: <br />Denx)lrtion Pcrnril\-Ashcsl{)s N(}tilicatiur Fcdcral Rcgulatiotrs ('l'illc 40, Pdrt6) <br />-Rcquircd <br />ktlcr of N(*ilicattrr <br />_l ccnily thal lhc fedcrrl regulations (..8uding ashcslos rcmrval uc ntl applicahlc b this pn)jcct. <br />X-l (cn ify tlrr\l hrvc Rd thrs epplreation drl stalc that the atxrve inli)rmalion is corccl. I agrcc b conrply with all City and County <br />irrdinan(cs nnd Shtc kws rcliting to huilding c(ustruclion, md hcrcl,y uulhorizc rcprescntativcs of this Cily and County lo entcr ufnn thc <br />atx)vc nrnti(trtcd pruFny lbr insprclion putFx)scs. <br />LI u,," flt6tlApplicnnl or Agcll <br />I'enrilcr namr <br />SITE.WORK DATE ID/S!G.COMMENTS <br />Set Backs <br />Forms/Steeli Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVl nsu lation <br />Roof Sheathing <br />Shear Wall <br />Framino <br />lnsulation/Energy <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 />Enqineer Final Report <br />Flood Zone Certif <br />tl \r ? <br />'Nhlht/d 4>1FINAL\hbru <br />Certificate of Occupancv <br />Notes, Remarks, Etc. <br />BUILDING. INSPECTOR RECORD <br />u^",i/7Xl'\ <br />,a1