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BUIL DIN G -IN S PECTOR RECORD
<br />SITE-WORK
<br />Set Backs
<br />Fo r m s/St eel/Ho ldowns
<br />Erectio n Pads
<br />UFE R Ground
<br />~ SLAB Fl oo r
<br />Su bfl oo r/Vent/l nsu lation
<br />Roof Shea thin q
<br />Shea r Wall
<br />Fra mi ng
<br />lns ul ation/Ene rqy
<br />Drywa ll
<br /><E xt)/l nt. Lath -
<br />Brown Co-crf .5c.fA-rtAJ
<br />Masonry
<br />Pool Fence
<br />T-Ba r
<br />Handicap Rea .
<br />Deputy Fina l Report
<br />Enqineer Fina l Report
<br />Fl ood Zone Certif.
<br />FINAL
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<br />I I
<br />Certifi cate of Occupanc y
<br />Notes, Rema rks, Etc.
<br />DATE ID/S IG . -C O MM ENTS
<br />I I I ,, I
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<br />l f ' (,111)
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<br />1/11(17 )AM(if) ~M. {Jib~ 4.a.< retr'&. f.rvH~, A ('(,-f'O,Jf 4./,tvJ.-t,. e~~fJ"'4_ nf._,
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<br />OWNER B U I Ll)ER l)EI.CA l!ATIO N
<br />I hereby nffirm under pc::nnhy or pc1j111y thm l am e:<cmpt from the Coutrnctors ' Liceuse L.1,,· for the followiug rcn~rn (Sec.7031.5
<br />Business mid Profession Code): Any City or County which requ ires a pcrmil to constn1c l. .iltcr. imprtwc, dc11m1\1l o r repair•any
<br />structure. prior to i1s issuance. nlso requ ires th e nppli cm11 for s uch pcrmi1 to file n signed stntc111cn1 1hm he or she is lkcnscci ptll'Sl~'lllt
<br />to the pro visions of the C'ontractor·s Lict:nsed L.,w (Chaplcr 9. Commencin g. wilh Section 7000 or Oivisio11 _:; or the Business and
<br />Profossions Code) or th nt he N she is exempt 1herefro111 and the basis rur the alleg ed exemption. l\ny \'iolation orSc<:tinn 70J 1.5 J:iy ,Jy
<br />applicant for a pcnnit subjects the applicant to a civil penalty of not more tha n fi ve h1111clrcd dollars l $500). "
<br />_I. as owner or the prope11y. or my employees with wages as their sole compcns.1tion. will do th e work ;mt.I the stnu.:turc.: is not
<br />intended ororTer ed for sale (Scc.7044. l3usinl-SS and Professions Cmlc; The C'ontrnc.:tor·s LIL'cnsc L:1w docs not npply to m1 O\\'ncr of
<br />the propt.--i1y who builds or improvl'S thereon. and who docs such work h imsclr or herself ur thr0t1g.h his or her t m ·11 emp lll)CCS.
<br />provided that such impro\'Cmcnls arc not inte11(lcd oroncrcd for sa le. If. however. the bu ild ing. rtr impn:wement is sold wi1hi n one year
<br />of completio n. the Owner Bui lder will h1we the b1irdcn o f proving tl mt he or she did not b11ild or i111prove th e pmpa1y for tl 1e p11q,oseof
<br />sale).
<br />_I. as owner oft he propc11y. mn c.-:clusively co111rn1.:ting with l it:ensed contrnctor~ to CC'lllStruct the prrije\'.t (Sec. i0•l•I. !111sin~
<br />and Profession Code: The Cont racto r's License Law docs 1101 apply 10 an owner or properly who builds or improves th,.:rt:tm .
<br />nnd who contracts fo1 such p10Jecls \\ 1th a Conll,ll"lru(s) licensed prnsu,111I to the Cuntt ,u:lor ·s L11:c11st.: L:m)
<br />_I .1111 exempt undc1 Sect mn _______ ~•· ·B·. &J'Jlf~r th is rc,mm
<br />D ate _j_{-".13' ~r ,b O1\UCr tj "",ff/JJ..J.;.__"
<br />-1ro-R_K_F .. ,1"'1s"'·--c-o_;~:..11-=,E=c,N_S_A_II_O_N_' -------------
<br />V ECL ARATIO N
<br />I hereby arftrm und er penalty of pciju1y one of t he fol lowing. declarat ions:
<br />_I have aml will nmintnin n C'c,1 ificntc ofC'ousent to Self-Insure for workers· compens.lt ion. ns prov id ed for by Sectit,11 >700 of the
<br />Lnbor ('ode. fo1· the performance of the work fo r wh ich the pt.,111i1 is issued.
<br />_I have and will 111ni111 ni11 workers· compcnsatirn1 ins ura nce. ns required by Sect ion .HOO of th e 1.-.,bur C:utlc:. for the p,::r li.H ma11 ce of
<br />lhe work for which 1his pen nit is issued. My wNkcrs· compensat ion insurnncc c.iffier ,md pol icy num ber (I.re:
<br />C"nffier: __________________________ _
<br />Policy Number: _____________________ Expircs: __________ _
<br />_I cc11 ify th nt in the performance of the work for which this permit is is~;ucd . I shnll not employ any person in an~ manner
<br />so ns to become S\tbjcr:I to the workers' compens,11io11 law!'. orCalifornin. and ng.ree tlmt if I slmul d bcco111c sub.iel·t h-' the
<br />workers' compensation provisions of Section .,700 oft he Lnbor Code, I shall. fm1hw ith cnmply with those prnvisirn 1s.
<br />WARNING : Failure to seC11 re workers' compensmion ClJVcrage is uni, 1vJ l. :met shall subject an employer to nimi,ial ptimlt ies and
<br />civil fines up to one hundred thousand dollars ($100.000). in ndd i1iij y 1_,
<br />11
<br />1hc c1,s1 o f compensation. dam.lgcs a s pnHidcd for the
<br />Section 3076 oft he Labor Code. interest and attorney"s fees. ,,
<br />Dale: ( ('--~,--(k, A1>11lir:1111:~~K __ ----l----1i~vL~-WA_-=-___,,, __________ _
<br />Ll<"EN~cll C<M<T RACTOII
<br />V ECI.ARA TIO N
<br />I hereby a mrrn under µcua lty of perjury thflt I nm licensed u11dcr pm visi m 1 of C'h npler 9 (com111c111.:i11g. wit h Sect ion iOOO) of Division 3
<br />of the Business nnd Pro fess ions Code. and my license is in full force and crTcct.
<br />License Class: ______________ Liccnse Num ber: _______________ _
<br />l)ate: ___________ Contrncl or: _____________________ _
<br />C O NSTRUCTION LENDING AGENCY
<br />I hereby nni nn und er pcnnlty of pe1jury 1lrn1 th ere is a construction lending agenc y for the pcr formnncc o f tin: work for whid1 t his pc.,in it is
<br />issued (Sec. 3097. Civ. C.).
<br />Lend er·s Name: _________________________ _
<br />Lendcr·s Address: _________________________ _
<br />A l 'l'LICANT DECL A RATION
<br />I hereby allinn under penalty of perjury one of the fo llow ing dcdnrations:
<br />Demolitio n {'cnnit s-Asbcstos No1 ifi c.i1ion Feder.ii Rcgu l.itions l'fit lc 40. Pnrt6)
<br />_Require d Let1er ofNotificntion
<br />_I ct.-,tiry thnt the federal regulations regarding nsbcs10s removal arc 1101 npplic able 10 this projec1.
<br />_1 cert d'y thm I have rend tins apphcation an~w:tc that the alxwe 111fo 1111at1on 1s co n ect I t1 gree to comply w11h nll C1tv anli County
<br />ordumnccs rmd Stntc Lm,s 1clnt mg to bud dm! · nst111c110n. nnd hc1cby authonze 1ep1esc111at1ves of tlus C'1t y nnd County lo cntt.,. upon the
<br />above men tioned prope11y for ms pec\lon puq
<br />Appllcnnl or Agcnl S ig natu re ~ --71 , I\. I).,,. I ( -'6 ~r b
<br />Pe nnil~c name (pr inl): ___ 1fh,w,_._,.LLL:.-:Jt..,__ __ \)..:.,._,____,,_ ______________________ _
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