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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS (rnerBuild.r DGlmtio. I h.r.by cfirm unds pcruhy oaperjurr lhar I am.xemA form rhe Cont{ctos L'c.n,.liw for thc lollowrns r6on (se 7031.5 B6in6s md Prof.ssioh Code): /\,, Cirt or County Nhich r<uir6 a pcmn ro coNtrucl. ah.r, tnprov., d.,nolirh or r.pan ay stru(uc, pnor ro 3 issuanc., also rcqut6 lhc spplica.t torsuchp.mnto fikrrisn.d stat.n. thal hcorsfic is liccos.d puBuant toth.prcvisionsofrh. Co.h.roar Lic.d.d hw (Chaflq 9. ao mencing wnhSerion TCOoolD'viion 3 ofrh.Bur'n6s ind Prol6sos Codc) or thsl h.or shc h cx.mpl lh*.fto'n a.d lhc bak aor th. rll.s.d .x.nprion .Any violstion ors.crion 70ll.t by any appli.a.t lor s p.mit subj.cts rh. .pplicanr ro a civil p.,!lry oamr hoi. rhe iir. nurdr.d doum ($500). L d ownd ol rh. pmp.nr. or m, .mployc6 w ith w.g6 !s th.i sol. cor.p.nsr ion. will do lh. *ork and rh. srudu. is nor i c.d.d orofIcredfors.lc(Sec7044,Burn6s.ndProfess'otuCode-IheContactoisL'censcLlvdo6norapplyrocnoqnerolrhepDp.n, lho builds or nnpror6 th.Eon. and who '106su.hwork hims.lf or h6.lt oi tbroush hk dr h( own .nploy.6. prolid.d rhlr such improrcm.nrs tuc.or inrmd.d orofer.d rorsal. lihowcvc,.rncbuildiocornnprcv.m.ntissoldvithinoney.arorcompl.iion,rh. owns Buildn willhav.ln. brd.o ofprovins rhal h. orsh. nol build or inpror. aor rh. purpos. ofsal.) l. s own.r of lhc propdy. rn.rclusiv.ly contddins*ith lic.6.d conrractoE ro coNlruclth. p,oj.cr ( Scc.7044. Busin.ssand Prcf.$io. Cod. Th€ Co.l.ac(ols Licem. t *dodm!6pply(ornown.rofpropdywhobu,ldtorinrpro!.erh.r@n,lodwho contacts for slch lrojeB *nh a contacro(3) I'c.n$d pu*xaf,r io rh. Contrdois Lr.o* Llw ) I M .xcnpr und6 S.crioo B &PC Lrrhhr..\.n _ I hiv..od*illmii .ih a Cdinc6i. oacotu.rr ro S.laj.sur.lor so,k.6 conp.Mr6n, as provd.d lor byserion 1700ofrh. hbor Cod., ror rhe prronmncc o r rh. wo fo,lhicn thc p6nil G issu.d I havesnd{ill m.rnhir rorle.a compensar'on rsurince, at requredbySectonl?OoofrhetrborCodeforlhcpcrforEoc.oilh€ work ior whrh rhup.rmn '! asued Myworlcs comp..stioo osu.@cc crir and policynurb.rsE: lw'.\ (Thirs..liono..dnolb.conrld.nifrhcpmirisforolr.hundrcddollaBltl00lorLss) I..niry$.1in thc pcrforunc€ of itc eort for whichlhisp.mit is isu.d.l shrll,ol mployrnyp.Roo i. an, mann.r !o s lo baan.subjecilo th. Mrk.s compenstion Lws ofCrliforni..andagr& rh.r 'lI should bccom.subJdd torhe workeB' compcnslion provi,ios oa Seiion l7l)0olrh. hbor Cod.,I shall. ronh*ith conply *irh rhoe porisio.s. WARN ING Fa' lur. ro s-ure vork.6 .omp.nel'on cov€rage B unl.qf!1, and sh.ll sobler in enrploy€r o criminal p.Mlri6 and cifil nn.s up kronchundr.dlfioBioddollas($100.000).inaddilionbrh.cost ofcomD.nsdrion. d.h.,r.s s lrovid.d tor $c sdlioo 1076 of rh. hbor Cod€. 'nrer6r and aftrn.y\ fes LICENSED CONTRACTORS DECLARATION I h6.by tttm undcr p.@hy ofp..jury lhal I M lic.N.d unds pmvision of Cnaprd9(em.ncins wnh SErion 7000)olDivtion I of lh. BNin sand Proi.$ionsCod., r.d mylic.B. is i. tull rorce and.II<t co!lIa!Elro!_!E!D!!{clc!!cx I hr.by rmm Md{ p.Mhy ofp.4ury rh,l rhcr. i! a coNl&crion l.odins ag.ncy tor rh. pffoma.c. oflt worl forBhichrhis p.nbn ir irsucd (S( 1097, Civ. C.) 488LrCldr.:_D!CrAaAr9N D.holir'on P.nn $Ashcstos Noxncarion Fcd.lal R€sulalioN ( Inlc 40. Pln 6) Rcqun.d L€llcr of Norilic,lion I c.nifrlhlr lhc Ld.ralr.gularioos rqardin8 Bbsros rono\alir. nor applicabl.ro rhh proldr l.cnii thlr I hav. rcrd lhis lpplicltion snd srt. th.r th. rborc informdion is cod.d.I rsrc. ro comply with rllCny snd Comly ordinlnc6 and Sul. lr*s r.l.ling to buildins coGrructioa. and n rcby luthoriz. rcpres.nrrti!.s oarhG Cny !d Coomy to mr.r lpon thc .bov. n.nlion d prop€ny for inspdtionpuryosd Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor SubfloorfuenUlnsul Roof Sheathing Shear Wall Framing lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif / FINAL /7////u .aUa I Certificate of Occupancy / ,' Y L/L/ Notes, Remarks, Etc. MlWP51\Permit-hspection Foms\Buildi.glBp6ction Rocord.doc 03.31.06 WORKERS COMPENSATION DECLARA'TION I h.r.by afiim undq p.ullr oap.rjury on. of lhc aolloai.r delr.rio.s Applicaml Applicanr or a*6t siB.i Set Backs