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BUILDING- !NSPECTOR RECORD <br />SITE.WORK DATE 1D/SIG COMMENTS OWNER BUILDER DEI,CARATION <br />I hereby allirm under penalty of perjury thal I an exempl ftom lhe Coillmclors l.icense Las for the follring remon (Se.7031.5 <br />Busin6s and l,rofBsion Code): Any ('ity or County which re;uirs a pmnil lo con$nrcl. alto. irnpror( dmolish or lepair my <br />stntcture. prior to ils issuance. also requirs the applicant for such pennil to file a signed statenent that he or she is licensed pursuot <br />lo lhe provisions ofthe Contractor's l-icenscrl larv (Chapls 9. ('omnrencing sith Srtion 7000 ofl)irision J ofthe Businas and <br />ProfessiqnsCode)orthatheorsheisexernpllhflefiornandtheb6isforlheallcSedexernption. AnyviolalionofSslionT0:1l.5byany <br />applicantforapmritsubjstslhc applicantloacivilpenallyofnolillorelhanfi\'ehundreddollus($500). <br />_1. c owoq of lhe fopefly. or rny employm rvith rvags m their sle compcnstion. will do the $'ork md lhe slrudm is nol <br />irlmdetl orofferedforsle(Se.T044.tlusindsandProf6sionsCode:-lheContraclor'sLicenselawdosnotapplytoanowntrof <br />thcprcpoly shobuildsorLnprovethson.mdrvhodoesuch*orkhimselforhoselforthrcughhisorhoou'nemployee. <br />providetl that such imFovqrf,ts tre not intflded oroffsqj for sale. lf, howfls. the birilding or imFrovsnsl is sold wilhin one )w <br />ofcompletion. the Olns Buildo will have thc budo ofproving that he or she did not build or impreve the prcpoly for the purfns of <br />sle). <br />l. 6 o$atr ofthe propqty. m exclusively contracling with licensed contracloE to construct thc projd (S(. 7044. BEins <br />and PrclcssbnCode:-[heContraclor'sLic€nse[,awdoesnotapplytoanowneofptopertywhobuildsorimprovesthereon. <br />and who contmcts for such projsts with a Conlmcto(s) licflsed pu6umt lo lhe Contractor's Licffc taw). <br />I m exemDl uodq Sstion-, B. & P.C. for lhis redon. <br />Dite: <br />I hereby <br />()$ncr: <br />\\0RKI.:RS' ('OI\I PI.]NSA I ION <br />l)E('l.AL\ ltoN <br />one ol thc firllrrr'inu rlcclrrationsraflirnr uodo pmalty ofprjury <br />IhaveadrvillmaintainaCflificateofConsmlloSelf-lnsureforr\orkfrs'conrpensalion.o providcdforbySslion3700oflhe <br />l-abor Code. for the pofonnance oflhe work for which the pennit is issued. <br />I har,e and !vill maintain workem cornpcnsalion insurailcc. as rcquirctl by Scclion 3700 ofthc l-abor (bdc. ftrr lhe pofonnance of <br />rhe r\ork for \rhich lhis pennit is <br />(-arrier: <br />-7 -I <br />pnttcy Nurnter-r .94,5 <br />'Yd;"'p <br />66ot <br />r,rrrrlrrrr\illi,,rl ittsrrr.rttec e.rr t icr <br />Sfaf,( <br />md policy numbo ue: <br />-"9(9 rrpirc.' <br />I cdiry that in thc performance ofthe work for which lhis permit is issued. I shall not employ any person in any mmncr <br />so 6tobecomesuhiettothervorkm'compmsationlarvsofCalifirmia.andagrethatiflshouldb€come subjEtlothe <br />workes' comptrsation prcvisions ofSeclion 1700 ofthe t-ahor Code. I shall. fonhwith cornply wilh those provisions. <br />WARNING: Failurc lo seure lvorkrs'compeNation covmge is unlarvful, and shall subjet m mrphy-o to qilninal peflaltiG md <br />civil finesuptoonchundredthousanddollus($100.000).inadditiontolhecoslofcornpensation.dmagesmprovidedforthe <br />Srction -1076 of the I-a[rr ( odc. intqLslq/uu)md attomey's fea. <br />l)rte: t A Applicant:tvFv\f ./ v <br />9 (comrnmcing s'ilh Sstion 7000) of Division lI hoeby aflirm undcr porally ofpqjury (hat I aln licosd undtr <br />of the Businss and Profssions Code. md my licmse is irr full fotce ud effccl. <br />l,icense J <br />CONSTRUC'TION LENDINC AGENCY <br />I heieby allirm under grnalty of ptrjury lhat thqe is 6 coctruction lmding agmcy for the po fonnmce oflhe work for which lhis p€finit is <br />issued (Se. 1097. Civ. C.). <br />Lender's Narnc: _ <br />l,mder's Adrlrs: <br />APPLICANT DECLARA'IION <br />I hettry affnn unds Fmalty of pejury one of thc followinli d(lilations: <br />Dcrnolition Ptrmils-Asbestos Nolificalion Fedsal Regulalions ('Iille 40. Pm6) <br />-,Required <br />Letter of Nolifi cation <br />with all City and (bunty <br />ald to mtE upon lhe <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenUl nsu lation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Energy l 4 <br />r Drywall-:I /rylfibtt .lhl-nrtu{ri6'>Lt <br />Ext.fnt. LatD p/3/ 't t)arttLlJ g lw{4YrfYbfh<{Nt/' <br />Brow-nEoat t/ <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />.t I I "/FINAL UbHilI ItMtbtl Ma6 <br />Certificate of Occupancy I <br />Notes, Remarks, Etc. <br />4 <br />",;^;;"-');,,10f <br />vf /o ( oiltrnctor:)</$ti1tt; <br />Pcrfl itee nanle (print):V4fflt <br />aI)atc: