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BUILDING. INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG.COMMENTS OWNNR BUILDI'R DELCARATION <br />I hcrcby aflirm undcr pcnillty of pcrjury lhal I am cxcnpl from lhc ContrachN' Liccn* lrw for thc fotlowing rcason (Scc.70.ll.5 <br />Busincss aml Profcssion Cule): Any Cily or Counly which requircs l rrmil lo conslruct. allcr. improvc. dcmolish or rcFir any <br />slruclure. prior to ils issuancc. also rcquires the {pplicant for such Frtrlil to l'ilc { signcd stalerrctrl lhal hc or slrc is liccned pursu'anl <br />to lhc provisi(ms of thc Conlractor's Licenrcd Law (Chaplcr 9. Conmrcncing wilh Sslion ?Un of Division .3 of lhe Busincss rnd <br />P()l'cssionsCodc)orlhatlrcorshciscxcmpllhcrcfro[rilndlhchdsisforlhcsllcgcdexclrplion. AnyviolationofssthnT03l.5byony <br />{pplicatrl for a pcrmit suhjccts lhe applicant lo { civil pcn{lly of nol trk)rc thrn fivc hundred dollars (S5fi)). <br />_1. as owncr of lhc proprty. or nry cnrployccs with wagcs as thcir solc conlpcnsation. will do thc work and the struclurc is not <br />inlcntlctl or oll'ercd lirr sale (Scc.7044. Business and Profcssions Crxlc: 'l'hc Contractor's l.iccttsc l-aw docs nol apply lo alt owncr ot' <br />the prn;rcrty who builds or itnprovcs thcrcrrn. atd who drrcs such work hirnsclf or hcrsclf or through his or hcr own enlployccs. <br />provi(lc(l lhal such irnprovcrrrcnls arc t'lot intendcd orofl'crcd ftrr salc. lf. howcvcr. thc building or itnprovcnrnt is sold withinonc yenr <br />of cornplction. thc Owncr Buildcr will havc lhc burdcn of provirrg that hc or shc did not build or irnprovc thc propcrty ltrr lhc puqmscof <br />salc). <br />-1. <br />as owncr ol'lhc propcrly. anr cxclusivcly corrlructirrg with liccrrscd conlractors to conslrucl thc projcct (.Scc. 7044. Busincss <br />and hofcssionCodc: 'l'hcContrilclor'sLiccnscl-aw<locsnotapplyloanowncrofpropcrtyu'hohuildsorimprovcsthercon. <br />and who conlracls l'or such pro.iccts with a Conlractor(s) liccnscd pursuant lo lhc (-ontraclor's Licensc l;rw). <br />-IatncxclnptundcrScctirllt-.B.&P.C.lirrlhis5pason.^.tr|,I)are: -8:3!41- u*,u,, <br />DECLARATION <br />I hcrcby al'flrnr urrdcr pcnalty ol'pcrjury onc of thc following declaralions: <br />_l havcandwill rnaintainaCcrtificatcol'C<lrrscrtltoScll'-lrrsurcltlrworkcrs'cornpcnsalior'r.as providcdfirrbyScction3T(Dofthc <br />Labor Crxlc. ltrrthe pcrforrnancc of thc work f'or which thc pcrrnit is issucd. <br />-l <br />havc arrtl will rtrainlain u'orkcrs'corn;rcnsalion insurancc. :rs rcquircd by Scction 37(X) ol'lhc Lahor Codc. for lhc pcrlirrnrancc of <br />lhc work krr which this pcrmit is issucd. My workcrs' conlpcnsrtion insurancc cirrricr and prlicy nunrtrcr arc: <br />I <br />Policy <br />-l <br />ccrtify thal in lhc pcrlbrnurncc of thc work firr which this pcrnrit is issucd. I shall not employ any pcrson in any nlanncr j <br />so as lo bccornc subjcct lo lhc workcrs'compcnsatiolr lau,s of C-alit'orniir. arrtl agrcc thal il'l should bcconrc subjcct lo lhc <br />s'orkcrs' corrtpcnsation pnrvisions of Scction .1700 of the Lttxrr Crxlc. I shall. lorthwith cornply with thosc provisions. <br />lVARNIN(]: Failurc lo sccure wrlrkcrs' compcnsaliorl covcragc is urrlawl'ul. antl shall suhjccl an cnrpkrycr to crinrinal Jrcnaltic's and <br />civil lincs up lo onc hundrerl thousand dollars (SlOO.ffiO). irr additiorr lo thc cost of conrJrcnsalion. danugcs as providcd lbr the <br />Scction -1076 of lhc l-ahrr Codc. intcrest and atlorrcy's fccs. <br />Dare:- 3: ?:--la--- Appr,rrrr, -ffigfi& AJ44'4 <br />r rcFr\sED ctx'rmctOn <br />DECLARATI(TN <br />I hcrcby afl'irru undcr pcnalty of pcrjury that I arn liccrrscd undcr ;rrovisiorr ol'Chaplcr 9 (corrrrncrrcing with Scction 7fiX)) of Division 3 <br />of lhc Ilusittcss iuttl Prol'cssions Code. and nty liccrrsc is in lirll tirrcc arxlcllccl. <br />I.iccrtsc Class: Liccnsc Nurrrr^ur: <br />Date: ('ontrnclor: <br />C(INSTRUCTION LENDING AGENCY <br />I hcrcby amrm undcr lrnillty of ncrjury th0t lhsc is a conslructhn hndir8 aScncy for thc pcrformncc of thc work for which lhis trcrmit is <br />issued (Scc. 3(x)7. Civ. C.). <br />l*ndcr's Nanrc: <br />l.cnrlcr's Adtlrcss: <br />APPLICANT DECLARA'TION <br />I lrcrcby allirrn untlcr pcrtalty ol'pcrjury onc of'lhc firlkrwing <lcclarations: <br />Dcrnolition Perrnits-Ashcstos Nolification Fcderal Rcgulations ('l'itlc 40. Part6l <br />-Rctluircd <br />Lctlcr of Notitication <br />-l <br />ccrlitythat thc l'crleralrcgulaliorts rcgardirtg ashcslosrcrrtovalat'c nol ryplicahlc to this pro.icct. <br />_l ccnify that I havc rcad this application ard statc thrt thc ilbvc informstion is corcct. I trgrc to comply with all City and County <br />ordinances and Stalc hws rclating lo building construction. and hcrchy rulhorizc rcprcsntativcs ofthis Ciry md County to cnts ulnn tlE <br />atnvc mcnlioncd pmpcrty for insgrcqirfnjurpes. <br />Appric.trrorAsenrs t["rt"*, W Yt--YQ,+r*t o"n g' iO'(r <br />Pcmltee mme (pdna)r_ _ <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor n <br />Su bf loor/VenVl nsu lation /\\ <br />Roof Sheathinq lo-1 \) "w,i:,:\Shear Wall V \-/ <br />Framinq <br />lnsulatio nlEnerqy <br />Drywall I <br />Ext./lnt. Lath "{XU/) <br />Brown Coat I L/ <br />lt/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Fina! Report <br />Flood Zone Certif <br />t I \,l <br />FINAL -U -,D[\rpc lrwb7 <br />Certificate of Occupancy 1 I V <br />Notes, Remarks, Etc.