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ECORDItBU!LDIN <br />SITE.WORK DATE COMMENTS <br />Set Backs <br />ID/SIG. <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/Ve nt/l ns u I atio n <br />Roof Sheath <br />Shear Wall v+t4 <br />Fram <br />lnsulation/Ene <br />Ext./lnt. Lath <br />Brown Coat <br />ltlaso <br />Pool Fence <br />T-Bar <br />Final R <br />En neer Final Re rt <br />Flood Zone Certif <br />FINAL <br />Certificate of <br />wtt-t--*z <br />at'lirnr untlc'r pnalty ot'pcrjury that I am L-xcnrpl lrrrnr thc- Contraclors' I-iccnsc l-aw lbr thc\lollowing rc:ison 6c.7g.l 1 .5 <br />Bustrcss arxl P(rtbssiur Colc): Any Cily or County which rcquircs a Jrcrmit k) conslnrcl. nllcr. inrprolc. dcm)lish or enair tny <br />stnrchrrc. [rr)r lo ils issuance, also rcquircs thc rpplicant li)r srch lrrmit k) lilc a signcd slalcnrnl lhnt lE or shc is liccn*rl pursuatt <br />k) thc pn)visr rns of tlrc Contr{ck)r's Liccnscd 1.{w (Ch{plcr I, C()mnrncing wilh Scction 70()0 of Division .l of thc Busircss a,rt <br />Pnrfcssi(]nsCrdc)orthathcorshciscrcml]tthcrclh]nrandthchilsislbrthcallcgcdcxcmpti(rn. AnyviolationofSccti(]n70.ll.5hyany <br />applicantfornpcmilsuhjeclsthc applicnntk)acivilpcnaltyofm*m(rrcthnnlivchundrcddollars(5500). <br />_l,as owncrol'lhcpn)pcrly,ormyemplttvccswithwagcsaslhcirsolcconrpo'^ltsalion.rvilltklth**wrlrk:urdtlrcstructurcisntlt <br />inteptJed qr otl'crctl lirr salc (Scc.7044. Busincss anrl Prrl'cssions Ciile: 'l'hc- Colrtraclur's l-iccnsc Law docs not apply to an tlwncr ol' <br />thc pn)pcrty wtro huiltls or inrpnrvcs tlrcrcon. arrd who dr;*-s such work hirttscll' or hcrsc'lf or thntugh his or hc'r own cmpltlyccs. <br />salc). <br />pr()pcrty. anr cxclusivcly contracting with liccnscd t:onlrltckrrs lo constnlct thc prrljcct (Sc-c. 7(144. Iltrsilrc-ss <br />anrl <br />antl <br />C<tdc: J'hc Corrtraclrlr's l-iccnsc- Law drrcs lrot apply lo an owncr ol'prrtpe-rty wlro builtls ttr imprttvcs llrercon. <br />wlro contracts tilr such projccts with a Contraclrlr(s) liccnsctl pursuant kr tltc Conlracttlr's l-iccnsc Law;. <br />_l anrcxcnrpt undcr P.Cl. lirr this reason.y-*?t-/q <br />DECLARA'tION <br />I hcrchy ll'l'irnr untlcr 1--nalty ol'J^-rjurv olrc' ot'thc litlkrwing dcclaratiotts: <br />Lahlr Crxlc. lirr thc Jrcrlirrmancc of thc' work lilr whiclr thc- Jrcrnrit Ls issucd. <br />thc work lirr which this 1^.^^rntil is issucd. My wrlrkcrs' c()rnle-nsalion ittsuriutcc can'icr antl pllicy nunlh('r arc: <br />Policy Numbcr: Expires: <br />ily that in thc 1**rlirrnranec ot thc work lirr wlrich tlris pcrnrit is issucd. I shall nol cmpkry any pr'rsotl in any nlatlll!-r <br />so :is lo hcconrc suhjcct to lhc wrlrkcrs'compcnsation laws ol'Calilirrnirr. and acrL-c thal il'l shrluld r-bcomc suhjcct to lhc <br />workcrs' conrpnsation prrvisions ol'scctiorr J7(X) ol'tltc Lahlr Ctxlc. I shall. torrhwith comply with thosc prrlvisions. <br />IVARNlN(i: [;ailurc to sccurc wrtrkcrs'contpcnsalion covL-ragc is unlawlirl. and slrall subjcct ln entpkrycr lo criminal Jrcnaltics arlrl <br />civil lilrcs up to onc- hurrdrc.d th<lusand dollars ($tm.Uru). in addition to thc cost ol'contpcnsation. ttantagcs as providetl tirr lltc <br />Scction .]076 of thc Latxlr Code, intcrcsl and attorncy's I'ccs.,:4aa.al <br />I,ICENS F]I) ('0N'I'R,\C1'() R <br />I)I.]CI,ARA'TI0N <br />ol' thc- Busincss and Prol'cssions Codc. antl my liccttsc- is in lirll ftlrcr- attd cltccl. <br />Liccnsc Class: Liccnse Nunrbcr: <br />W <br />I hcrcby afnrm undcr Fnalry ol Frjury th.t thcrc is a construclion lcnding dgcncy lhr thc pcrli)mBtuc (rf thc work lirr which lhis tErmit i\ <br />issucd (Scc. .1097. Civ. C.). <br />[xndcr's Namc: <br />[rndcr's Adtlrc'ss: <br />APPLTCANT DECLARATION <br />I lrcrclly allirnr undcr pcnalty ol'prjury onc o[ thc ltrlkrwing dcclarations: <br />Dcnxrlit ion Pcrnrits-Ashcstos Notification Fcdcral Rcgulat ions ('l'itle 40, Pan6) <br />_Rcqu ircd lrttcr ol' Notilication <br />ccrlily that thc l'cdcral rcgulations rcguding ashc'slos r(-m()val arc not ap;llicahlc lo lhis pnrjc-ct.* <br />ccrl il'y t hrrt Ituvc rcatl t his rrpplicul iott anrl sl ltlc that tllt-alxrvc'inlirrntation is corrccl.agrce lo crlnrply <br />ivcs ol'this City <br />with all City and Cottttly <br />and cOunty to cntcr ugrn tlrcandStatcLawsrclat ing lrt huiltlirrg cotrsl ntcl irttt.arrl hcrchy :tttl lxrriz.c <br />abovc nrcrrtioncd protru*rty lirr inspccti()n Eryf)scs.Luor Agent <XC,a <br />Penrrilet'nanle <br />?h l/' <br />t'cl)t c\L'nlat <br />7- /- l? <br />) <br />7)!