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SITE-W ORK DATE ID/SIG. Set Backs Form s/Stee l/Ho ldowns Erection Pads UFER Grou nd SLAB Fl oor Subfl oor/Vent/lnsulati o n Roof S heathin g S hear Wall Framinq Insu lation/Energy Drywa ll Ext.II nt. Lath B rown Coat Masonry Pool Fence T -B ar Handicap Req . Deputy Fin al Report Engineer Final Report Fl ood Zone Cert if. _.,. FINAL "r'f'] I I 1i ~ I/,/ 2..:1 Ce rtifi cate of Occupancy Notes, Remarks, Etc. BUILDING-INSPECTOR RECORD crnv'IMENTS • O WNEI{ IIUILIJl,R IJEI.C'Al{ATION l hereby amrm und er pcnn lt y or pc1jury thm I run exempt from the Co n1rn c101-s· License Lnw fo r 1hc followi ng rc:iso n lScc. 703 1.5 Busi ness and Pro fession Code}: Any C'ity or C'ou nt)' which requires a perm it 10 co nst ruct. .ihcr. improve. dcmot~h or repair any s1ructure, prio r t o i ts iss unnce, nl so requires t he npplirant for 5uch pennit to fil e n signed s1n1c111r 111 1hn1 he o r she is l icensed pursiAant to the provisio ns of the Contrncl or's Licensed Law (Clrn pl er 9. C'om menci11g with Sect ion 7000 (,f Division _l t1 f the Business bnd Pro fessions Code) or t h.it he or she is exemp t lh crcfrmn and the basis for the alkgeU e:-:cmpt km. /\ny violat ion of SecliC1n 7031.5 by any a pp licant fo r a permit subjects t he appl ica nt to a civil penalty of not 111orc th.tit five hundred dollars ($500). _I. ris owner of1h e propert y, or my employees with w ri ges m; their sole compensr11io n. will do 1hc work :md the s1ruct 11re is no t intended or o ffered for sale (Sec. 7044. Business and Pro fessions Code: The C'o ntrnctor's License L.1w do(.'S no t npply lo 1111 nwner of t he propc1ty who bu ilds or impro\·es th crron. and who does such wo rk himsel f or herself or 1hmugh his or her own employees. provided that s uch imp rovements arc not int ended oroff1.,·ed for sale. ir: howc\·er. the buildi ng or impro\'cment ls sold wi1 hin one year of complc1ion. the Owner Bui lder will hm·e 1hc burden of proving that he or she did not bui ld or impl'O\'C !he propt . .,1)' for the purpose of sa le ). _I. as owner o f the propt..'t1y, am exdusi\·ely contract ing wilh licensed co 111 n1c101-s to co11strn c1 1hc project (Sec. 7044. Ot1sincss and Profession Code: The Contractor's Li cense Ln w docs 1101 apply to an owner fl f propc1iy who builds or impmves thcrenn. ;md who co nlrac ts for such projects with n C'ontraclor(s) licensed purs u;mt to 1he Cn ntrnctor's License Lm..,·). _I am e:'<e mpt under Sect ion ________ . 13. & P.C. for thi s reason. Date: __________ Owncr:~==·========~------- WOllKEllS' CO~l l'ENSATION IJEC LA llATION I hereby affirn 1 under pena lty of pc1j uryonc of1l1c fo llowin g dct.·larat io1 1s: _I hnve and will maln ta i,1 a Ce11 ilic at c of Consent to Self-Insure for workers· co mpensat io n. as provid ed for by Sect inn J700 of1he La bor Cod e. fo r tl1c pcrfonmmce oft he work for whic h 1he perm it is issued. _I have and wil l nm intnin workers· compc nsnt ion insurnncc. ns rc(]tti rcd by Sec1 ion J7UU of the Labor Code. for 1hc pcrfonrnlnce of th e work for wh ich th is pcnn it is issucxl My workt..,·s· compcnsntiu n insurance CtHiicr aml 1xilicy num ber arc: Ca11"ier: __________________________ _ Policy Numlx:r :. _____________________ E:(pircs: __________ _ _I cert ify th.it in the performance of1l1c work for wh ich this permit is iss1 1ed. I sh.ill nnt employ any person in :111 y 111:-inncr so :-is to become s ubject to the worker s' compensatio n la ws l,f (';ili fornin. and rig.rec tlrnt if I should bccumc subject 10 the workers' compensat ion prnvisinns of Sect io n ~700 of the Lnbn r Cod e. I shall. fm1hwi1 h i.:m nply with 1hose µrovisiim s. WARN IN C : Failu re to secure workers' compensation coverngc is unlaw ful. and sha.11 sub,iect an employer to criminal pcrinlties and civil fines up to one hundred tho usand dollars ($100.000). in addit ion to the cost of co111pc11~.11ion. damngcs a s proviUcd for the Section 3076 of the Lalxll' Code. interest and attorney's fees. Uatc: ___________ A1l plic;1111: _____________________ _ LIC ENSlcll C O NTllACTOll IJECLAl{ATIO N I hereby nllirm under pena lty of perjury thi11 I nm licensed under pnwision of Chapter 9 (commenc ing \\'ilh Section 7UUU ) nf Uivision 3 o f th e Business and Pro fessio ns Code. and my lice nse is in full fo rce mid effect. L icense C tnss: ______________ Liccnsc Nu mber: _______________ _ Dn1c: ___________ Contrac1o r : _________________ _ CO NST l{UC TION LENDI NG AGENCY I hereby affirm uml ~r pcm1lt yof perjury th at I here is a c-onslruct ion lend ing .igcncy for the pcrfon nancc of t he work fo r which this pennit is issued (Sec. 3097. ('iv. C.). Lendcr"s N.ime: _________________________ _ Lender"s Address: _________________________ _ A PPLICANT D ECL ARATIO N I hereby allinn under penal ty of pe1jury one of th e following. declarations: De molitio n Permits-Asbestos Not ification Fede ral Reg ulalions (Till e 40. Pm16) _Rcqui,·cJ Lcttcrof Notificat ion _I cer1 ify 1hnt the fcdcrn! regulatio ns regnrdin g asbestos remova l nre not npp!icable lo this project. _I ccii1fy th nt I Im c rend tlus npplu.·.111011 and st nte th nt the nbg~ 1nfmnm t1on 1s con eel I ag1ce 10 comply wi th :ill C ity :iud County 01dmn nces nn d Srnt e L1\\S 1ela1,111g 10 budd111 1 ~'~)11c11~11. nnl rebyJ1utl/e 1ep1ese11tnt1\es of1l11s Cit y and Counlytu t.:nler upon the nbove mentioned p1 opcrty fo1 m ·tton pu1 (.;s/ , tr"" .-:--1 .0 Q. Ap pli ca11l or Age111Si g1m1t11e -i Dale r-L _o~ I I Perrrritcc na me (11ri111):~=J--~•----<T"I---./~ •~.1...+-,,_,_/}~-f-Jc__b-j-_.,_ __ -1\~/_.f..,A'-'----------•-_ I V