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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/S!G.COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby allirm uftlcr 1Emlly of Frjury that I am cxcmpt from thc CoNracklrs' Liccns Law tbr thc li)lk wing rcartn (Scc.70.ll.5 <br />Rusilcss anl Prolcssion CGlc): Any City or County which ]cquires a JErmit kr conslruct, altcr. improvc, dcm]lish or rcpair any <br />structurc. [rirr to its issuarec, al$ rcquircs thc applicant tbr such Jrcmit b l'ilc a signcd slrlcmnl that hc or shc is liccn$d pursu{t <br />to thc pn visions of thc Contractor's Licenrcd law (Chaplc] 9, Comcncing with Scction 70U) of Division 3 (tf the Busincss and <br />Pnrfcssions Codc) or that hc or shc is crcmpt thcrcfrom and thc basis for thc allcgcd cxcmpti(rn, ADy violation of Section 70J 1.5 by any <br />applicant li)r a JEmit subjccts thc applicant to a civil pcnalty of not morc than livc hundrcd dollars ($50O). <br />I <br />_1. as owncr of tlrc propcny, or my cmployccs wilh wagcs as thcir eh comFlsation, willdo thc work uxl lhc slrulurc is ml <br />intcn Nl or ollcrcd lilr Mh (Se.7(N4. Busincss and PKlfcssions Cdc: Thc Contrdclor's Liccn$ kw docs nol aplly lo an owncr of <br />rhclmllrcrty wlx)buildsorimpmrcstlrcB)n,arxlwhod(rssuchw)rkhimsclforhcrsclforthroughhisorhcrowncmployccs, <br />proviJcd that such imlmrwmnls re ft)t inlcffl,ql or ollircd lbr slc. Ii lx)wcwl thc huiLling or inlrcrcmnt is vrll within orc )84 <br />ol $nplction, lhc Owncr Buil.lq will havc lhc bunlcn of Frving thlt hc or she did mt buiLl or imJrorc ilrc Jmrls(y lbr (hc purlDs of <br />sh). <br />_1. as ()wnc.r ol'thc pn)pcrty. ant cxclusivcly contracting with liccn.scd conlraclors lo construct thc prc.icct (Scc. 7044, Busilress <br />and l1ot'cssiln Codc: Thc Contraclor's Liccnsc l-aw drrcs nol apply to an owner of propcrty who builds or improvcs thercott, <br />and who contracts filr such pr)jects with a Contractor(s) liccnscd pursuant to tltc Grntraclor's Liccnsc Law). <br />-l <br />amcxcmpt under Scction-, B. & P.C. lbr this rcason. <br />WORKERS' CONIPENSATION <br />DECLARATION <br />I hcrchy all'irnr undcr Fnalty of pcrjury one of thc tirlklwing dcclarations: <br />/ <br />_l havc arxl will maintain a Certiticatc of Conscnt t<l Sclt'-lnsurc li)r wrlrkers' comgrcnsation, as providcrl tilr by Section -1700 of thc <br />Latxlr Grdc, lirr thc Frcrli)rmance o[ thc work l<lr which thc pcrmit i.s issucd. <br />6 nuu"and will maintain wrlrkcrs' comJrcnsatiorr insurance, as rcquircrl by Secrion 37il) of thc l.-abor Codc, tirr thc Jrerlirrmance of <br />\ thc work lirr which this Frcrmit is issued. My wrlrkcrs' c()mpcnsation insurancc c.uricr and;xllicy numbcr <br />Oyr ,q L <br />lron.y s -L <br />_l ccrtity that in thc Jrcrtirrmancc of thc work lilr which this Jrcrmit is issuctl, I shall not cntploy any pcrs()n in any manncr <br />so as to hcconrc subjcct lo thc workcrs' compcnsation laws of Calililrnia. and agrce that il'I should bccomc subjcct to thc <br />workcrs' comJrcnsation provisions of Scction 1700 ol'lhc Latxlr Crxlc. I shall. li)rthwith comply with thosc prtlvisiolts. <br />WARNING: I;ailurc to sccurc workcrs'conrpcnsatiot't covcragc is unlawful, and shall suhjcct art cntploycr to criminal Jrcnaltics and <br />civil lincs up to onc hundrcd thousand dollars (S100,Uru), in additiort to thc cost rtl'com[rcnsation, damagcs as providcd lilr thc <br />Sccti<ln 1076 ofthc [-ahrr Crxle, inlercst and attrlrtrcy's l'ccs. <br />4r1 {L^o e <br />I.I C]ENSEI) CONTITACTO R <br />I)ECI,ARATION <br />I hcrcby atlrnr untlcr Jrcnalty of Jrcrjury that I am liccnscd undcr provision of Chaptcr 9 (commcncing with Scction 7firu) of Division .l <br />of the Busincss and Prolbssions Codc, and my licensc is in lull tirrcc and ell'cct. <br />Kn,,"l tosCNumbcr: <br />C v\T <br />tN rn ,fi^l <br />I hercby allrm untlcr pcnalty of pcrjury <br />issucd (Scc. 3097, Civ. C.). <br />kntlcr's Namc: <br />CONSTRUCTION LENDTNG AGENCY <br />that therc is a construction lcrrdingt agcncy lirr thc Jrerlilrmattce o[ thc work tbr which this pcrmit Ls <br />t <br />[,cndcr's Addrcss: <br />APPLICANT DECLARATION <br />I hcrcby atl-rm under pcnalty of grcrjury onc of thc lirlkrwing dcclarations: <br />Dcnxrlitiorr Permits-Asbcstos Nolilication Fcderal Rcgulations ('l'itlc 40, Part6) <br />-Rcqu <br />ircd lrttcr ol' Notilication <br />I <br />-l <br />ccnily that lhc tbdcral rcgulatbns rcgddin8 ashcst()s rcmlval arc not applicahle k, this pRljet. <br />-(fccrtity rhar I havc (cad this alplicati(rr uxl st{tc that thc ah}vc inli)rmation is coret. I agre k) comply with all City and County <br />ordinanccs and StaIe llws rclaling k, building construction, anl hcrcby aullxrrirc rcprcscilativcs of lhis Cily and C(tunty to cntcr uFln thc <br />ahrvc mc-ntioncd proprty tirr inspcclion <br />, Applicant or Agent <br />\ Penrrilee nanre <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf Ioor/VenVl nsu lation <br />Roof Sheathing <br />Shear Wall <br />Framinq <br />lnsu lation/Enerqy <br />Drywal! <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 \-r1 .l -<-a <br />FINAL us w )[T J U <br />Certificate of Occupancv t <br />Notes, Rgmarks, Etc L I <br />-t )l\--+ <br />Elorr fiP*n7 -2n1q, <br />tt Dare: tz-/z-/z.oT