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BUILDING- INSPECTOR RECORD <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 /-31-2o kftalo3 <br />Shear Wall <br />Framinq <br />lnsulation/Eneroy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />lt/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />FINAL ,'Ul-",Ds?-tl l6:', <br />Certificate of Occupancv <br />Notes, Remarks, Etc. <br />OWNER BUIt,DER DELCARATION <br />I hcrchy afllrm undcr pcnulty of pcrjury that I am cxcmpt from lhc Conlrack)rs' Liccnsc hw for thc folk)wing rcasn (Scc.70.11.5 <br />Busincss lnd Prolbssion Code): Any City or Counly which rcquircs a pcnril lo constntcl. allcr, irnprrvc. dcmolish or rr;lair any <br />slruclurc. priork, its issuance. also rcquircs lhe applicant li)r such pcrmil to lilc a signcd strlctrrcnt lhal lreor she is liccnsc(l pursuant <br />k) lhc provisions of thc Conlrack)r's Licenscd hw (Chaptcr 9. Conlncncing with Section 7(Xn of Division -l of Ihc Busincss and <br />ProltssionsCodc)orthalhcorshciscxcmpllhcrcf()mandthebrsislbrthcallcgedcxcmption. AnyviolnlionofScctionT0-ll.5byany <br />applicilnt li)r a pcnrit subjccls thc applicant lo a civil penillly ol'not rnorc lhon llvc hundrcd dollars ($500). <br />_1. as owncr ol thc proFny. or ilry cilrployccs wilh wages as Ihcir \olc conrlxnsalion. will do tlrc work and lhc strclurc is nol <br />intcild orofTcrcdf()rsle(sN.7(!,l.Busincs\andProfcssir)nsCodcrThcColtrrctor's[-iccnscLjtwdocsnotapplytornowncrof <br />thc pR)pcny who builds or improvcs thcmn. md who d@s such srrrk hirnsclfor hcrscllor lhr)ugh his or her own enrpk)yces. <br />provi(lcd thal such itrrprovenrcnls ffc not intendcd orollcrcd tbr salc. ll. howcvcr. thc huilding or inrprovcmnt is sold within (ilrc ycnr <br />ofconllction. thc Owncr Buildcr will havc thc burdcn of provirg thill hc or shc dtl nol huild or inuovc the pnrpcfty for thc purF)r of <br />qlc).- <br />l. as owncr of thc propcrly. ilnr cxclusivcly contricting with liccnscd conlr ack)rs l() conslrucl lhc froicct (Scc. 7()1.1. Busirtcss <br />and l1\r'cssiolCodcr'lhcConlrrclor'sl-icensc[,awtlocsnolilpplylontrowncrofpropcrlywhohuildsoririlprovcslhcrcon. <br />anrl whi) coDtrrcls lbr such p(,iccls wilh r (i)rilrrcbr(s) liccDscd pursun0l l() lhc Conlrilclor's l-iccnsc l,rw). <br />lJmcxcmpluildcrscclion-.B,&P.C'forlhistcuson' <br />l)nlr:()rvnrr: <br />WORKERS' COMPENSATION: IIECIIISAIIQN <br />I hcrcby aflirm uldcr pcnaltyof pcrjuryone of rhc li)lk)wing dcclarationsl <br />_l havc and will ilrriltilin a Ccrlilicxtc ofCoilscill t) Sclf-lnsurc li)r workcrs conlpcnsution. rs providcd li)r hy Seclion .17(X) ofthc <br />lntx)r Codc. for lhc pcrli)rnunce ol lhc work lbr which thc pcrtrtil is issucd. <br />thc <br />havc and will nrainlain workcrs' cotrqEnsation insurance. as rcquircd by Sccli()n <br />which this pcrmit is isrucd. My wrrkcrs' comlcn\alion iil{urancc cafiicr <br />.: i,r1\ t atffL\ <br />-17([ ofthc lahor Codc. for thc pcrlbriluncc of <br />md Jxrlicy numbcr are:s1)rk lor <br />rzl3rCrrricr:LL(/ <br />Policy Nu <br />_l ccrlifythrti[thcpcrfornunccollhcworkli)rwhichthislcrnlitisissucd. Ishall nolenrlk)ynnypcrsoninanymililncr 4 <br />so xs lo bcconle suhjccl k) lhc workcrs'cornpcnsation laws ofCalili)inia. and agrcc lhal if I shorld bccomc suhjccl lo thc <br />workcrs'coilrpcnsillionprovisionsofScclion-17(X)ollhct{htrCodc.lshdll,lorlhwilhconlplywilhlhosprovi\ions. <br />IVARN]NG: Frilurc to rcurc workcn'colrpcnsnlion covcrrgc is unlawful. antl shall suh.iccl an cmplo;cr lo nimiilal ftnullics aBl <br />civil llncs up to onc hundrcd llt)usnnd dollars (S itr rdd lhc cosl of con{Ensrlion. danragcs as providctl fot the <br />Sccl')n ol Codc. intcrcsl <br />I)tlt:L?Z 1tj <br />I hcrchy afurm undcr pcnalty of pcrjury Ihat I am liccnrcd undcr Jrovision of Chuplcr 9 (commcncing wilh Scction 7000) of Division ] <br />of thc Business and Prolessions Codc. md nry liccnsc is in full li)rcc and cllccl. <br />\[-iccrrsc N u nrl_--r: <br />W <br />I hcrchy aulrm undcr frcnillly of pcrjury lhat lherc is il construction lcnding rgcncy lor the pcrli)nnuncc of the work lbr which this prrttil is <br />issucd (Scc. 1097. Civ. C.). <br />Lcndcr's Namcl <br />I-cndcr'( A(ldrcs\ <br />ATIIJCANLD&CLABAII9N <br />I hrcby alfinn undcr pcnalty of pcrjury one of lhc folkrwing dcclaralions: <br />Dem)lition Pernlits-Ashcslos Nolification Fcdcral Rcgulalions (Tillc 40. Pan(r) <br />-Rcquircd <br />kttcr of Notificalion <br />-l <br />ccrtily thrt lhc lcdcral rcSulalions reguding 0\bcslos rcrnov0l rrc Dol applicahlc lo lhis projccl. <br />this appliculion irnd stntc that thc atx,vc inli)rnlxli()n is (orrccl. I ilgrcc lo c()nll)ly with all Cily and Counly <br />buildiilg cotrslruclion. dnd hcrchy iluthorizc rcprcscntrlivc\ oI lhis Cily ilr(l County h cnlcr upon lhc <br />abovc ilrcntioned propcrly <br />Applicsnl or Agent <br />I'errrilrr trrmc ( <br />PUrJtscs. <br />Llgvl\ <br />.! <br />o^", r)2,b)ac) <br />^a <br />,","!|}{Ltr