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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 />Su bf loor/VenVl nsu lation <br />Roof Sheathing le'lq.2o <br />Shear Wall <br />Framing <br />Insulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />FINAL tt/2ru 5ry< <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />I hcrchy aflirm undcr lEnalty of Frjury lhat I am cxcmpl from thc Contraclos' Lilrnsc Law li)r thc followiryr rcovm (Scc.70ll.5 <br />Rusi[css afid Profcssiu Culc): Any City or County which rcquircs a fErmit kr lIrnstruct. altcr. improve, demrlish or rcpai any <br />sIructurc, lmor to rls is$uancc, also rcquircs thc applicmt for such IErmil k) tih a signcd slalemnt lhat hc or shc is licctrsd Jrursulnt <br />to thc pmvisions o[ lhc Grntractor's Liccnsd llw (Ch{pts 9, Commcreing wilh Section 7000 of Division -] of thc Busincss and <br />PntbssionsGxlc)orlhathcorshciscrcmptthcrcfromandthcbasisforthcallcgcdcxcmption. AnyviolationofsethnTO3l.5by{ny <br />applicant l(rr a Frmit suhj@ts thc applicant to a civil pcnalty of nu m)rc than fivc huftlrcd dollus 1$5fii). <br />.LD. a, o*rcr uf thc prupcny, or my cmployes with waScs as thcb slc compcnsation, will do thc wuk axl thc slruturc is nol <br />incnlcd or ollcrcd lirr slc (Se.7O44, Busincss and Prolbssions C(xlc: Thc Contrack)r's Liccnrc hw d(rcs not apply to an owncr ()f <br />thcpnlFny whobuikls()rimpmrcsthccrn,erdwhod(Essuc'hur*himsclforhcrslforthrcughhisorhcrowncmphyccs, <br />providcil that such imprcrcmnts rc mt itrtcftlcd or()llbrcd fi)r sb. If, horcvq, thc building or impKlwmnt is sokl within one 1rcu <br />olcomphlion, the Owncr Buills will hrrc tlE budcn oflrovilg that hc or shc dil nrl huill or ihprovc thc pn IEty for lhc purF s oI <br />sab). <br />-l <br />as owncr ol'thc pn)Frly. am cxclusivcly conlract irrg with liccnsctl contractors l() construct thc prl.icct (Scc. 7044, Business <br />and Prrrtbssirxr Codc: Thc Contractor's l-iccnsc Law docs not apply lo an owner of propcrty who huilds or improvcs thcrcon, <br />and wlxr contracts lirr such projects with a Contractrlr(s) licenscd pursuant to thc Contractor's Liccnsc Law). <br />-l <br />amcxcmpt unrlcr Scction_, B. & P.C.'imo^r", 7l Sol )a 20 ()rrlrer: <br />rvo n r s ns' co\*srx*tffilr <br />DECLARATION <br />I hcrchy al'l'irm undcr Jrcnalty of pcrjury onc of thc folkrwing dcclarations: <br />_l havc antl will mainlain a Ccrtilicatc ol'Consent to Sclt-lnsure lilr workcrs' comlrcnsation, as pnlvidcd tor by Scction -17fi) of thc <br />Labrlr Crxlc, lilr thc pcrlirrmancc of thc wrlrk fbr which thc pcrmit is issucd. <br />-l <br />havc anrl will maintain workcrs' comJrcrtsation insurancc, as rcquircd by Scction -1700 of thc Labor Codc, for thc Jrcrlilrmancc of <br />the work lbr which this Jrermit is issued. My workers' compensation insurancc carricr arxl Jxrlicy numbcr are: <br />Pohcy Numtrcr: Expires: <br />;!Qt ccnity rtrat in thc JErlormancc of thc work for which this lrcrmit is issucd, I shall not cmploy any JErson in any msnncr <br />so as k) hocom subject Io thc workcrs' comFnsation luws ofCalifornia, and agre lhat if I should bccorc subjert to lhc <br />wotlcrs'cl)mpcnsationpnrvisionsofSelion3T0OofthctrtrrCulc. Ishall,tbrthwithcrrmplywithllxr*pnrviskrns. <br />WARNING: Fdilurc k) scurc workcrs'(omlrcnsation covcragc is unlawful, and shall subjcct an cmploycr kr lriminal JEEltics aftl <br />civil lincs up to onc hundrcd thousand dollars (S100.Uru), in addition to ths cost of comJrcnsation. damagcs as provirled lbr thc <br />Scction 3076 of thc l.atxrr Cule, intcrcsl and attorncy's t'ccs. ,4 -, <br />o*", 7 /zolzoLo Appricanr: @-4'\ <br />I,ICENSED C()NI'R,\CTOR <br />I)ECI,ARATION <br />I hcrcby al'lirm undcr Srcnalty of perjury that I am liccnscd undcr provision of Chaptcr 9 (comrncncing wit h Scction 7firu) of Division -l <br />of thc Busincss and Prol'cssions Codc, and my liccnsc is in full lilrcc arxJ clfcct. <br />Licensc Class: Liccnsc Nunrbcr: <br />W <br />I hcrcby aflirm undcr JEnaltyof Frjury lh{t lhqc is a constructirn hnding agcrey li)r Ihc Jrcrfomncc (rf lhc work lirr which this Frmit Ls <br />issued (Scc. 3097, Civ. C.). <br />I-cndcr's Namc: <br />l,cndcr's Addrcss: <br />APPLICANT DECLARATION <br />I lrcrcby all'rm undcr Jrcnalty of perjury onc of the tblkrwing dcclarations: <br />Demolitiorr Pcrmits-Asbestos Notification Federal Rcgulations (Title 40. Part6) <br />_Rcqu ircd lrttcr of Notilication <br />_l ccrlily that thc l'cdcral rcgulations rcgarding ashcstos rcmovalarc not applicablc kr this projcct. <br />ccrtily that I luvc rcatl this application aml statc that thc abovc inlirrmation is corrcct. I agrcc to comply with all City and County <br />rlrdinanccs and State Laws rclating to building arxl hcrchy autlxrrze reprcscntatives of this City and County to cntcr uJxrn thc <br />ah,ovc mcntioncd pnr;rcrty lirr insJrcctirlrr <br />Applicant or Agent <br />Pernritee nanre ( <br />""", ?/ Jo/ zo)0 <br />n9,-n7 -2n 1 q <br />tbttfu frxY <br />At