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BUILDING. INSPECTOR RECORD <br />DATE ID/SIG.COMMENTSSITE.WORK <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenVl ns u lation <br />Roof Sheath <br />Shear Wall <br />Fram <br />I nsu <br />Ext./lnt. Lath <br />Brown Coat <br />lVlason <br />Pool Fence <br />T-Bar <br />Handi <br />Final <br />ineer Final <br />Flood Zone Certif . <br />-at-FINAL <br />Certificate of Occu <br />EtcRemarks <br />I hcrcby affirnr undcr Jrcnalty of Frjury that I m cxenrpt lh)m the C(rntract(E' Liccns Law for thc lolltwin8 reasn (Ss.7031'5 <br />Busincss and Profcssion Cqlc): Any City or G)unly which rcquircs a pmit to conslrucl. altc( impfltvc. dtmollsh Qr rcpaiI ily <br />structurc. lfirr b its issuancc, also rcquircs thc applicant lirr such Frmit k) lile a signcd statcmnt thal hc or shc is liccnsd pursuant <br />t0 thc pNisions of thc Contrack)r's Liccn$d Law (Chaplcr 9, Commcncing wilh S@tiotr 70U) of Division J of the Busincss and <br />pnlfcssion$ Gxle) or lhat hc or shc is excmpt thcrcfrom and thc basis for lhc rllcgcd cxemption. Any violati(in of Scrion 7!.1 I 5 by any <br />appticant li)r a pcrmit subjcts thc applicant kr a civil pcnalty of not morc thar fivc hundrcd dollils ($500). <br />_1, as owncr {!f lhc prulEny. or my cmpkryccs with wagcs as their sole compcnsation. will do thc work anl lhc stmtrc is ftrl <br />intwJc.! oroflcrc,lluslc(Sa.ZtXl.gusincssanrlPrufcssionsC(xlc'lhcConlractor'sLiccnskwd(Esnotapplykranowrcrof <br />thc prrlE.ty wlxr buills or imFovcs llrcFu. ur.l who d(rs such urrk himsclf or her*lf or thnrugh his or hcr own employccs. <br />p..ri!",Ith"tsuch impRrvorcntsenotintcdq!orollbrqlli)rsab. lilxtwcvctlhcbuillhgorim1mrcrcnlissldwithinoncycd <br />of conrpbtkrn, thc Owncr Buillcr will have thc burdcn of pruvin8 lhal hc or shc did ttrtt buil.l or imprcrc the p(rttIly lbr thc purJxrs of <br />slc), <br />_1. .s owncr of thc pmlrcny, an cxclusivcly conlracting wilh liccnsed conlrack)s to conslrucl lhc PrcFd (Se. 7044, Busincss <br />ml ProlbssimCo,lc:TheContractor'sLiccnscLawdocsnolapplytrmownerofprolErtywhobuildsorimprovesthcrcon, <br />and who cotrtracts for such pmjets with a contmck (s) liccnrcd pursuant b lhe contrackrr's Li@ns Law). <br />-[ <br />am cxcmpt under Sali(rn-' B. & P.C tbr this rcason' <br />lVO RK I.]RS' CONI I'ENSA'I'ION <br />I)F]CI,AI'A'I'I0N <br />I hcreby affirm under pcnalty of pcrjury onc of thc tbllowing dcclarations: <br />_l have arxl will maintain a Ccrtifrcarc of Conscnt to Selt-lnsure frrr workcrs' comJrensation. as providcd lilr hy Section -1700 of the <br />Latxlr Crxlc, lilr thc pertbrmance of the work for which thc pcrmit Ls issucd' <br />-I <br />haveanrlwillmaintainw6rkcrs'comJrcnsationinsurancc.as rcquiretlbyScctionlTfi)ofthcLahorC<ldc'tirrthcpertormanecof <br />thc work lilr which this Jrcrmit is issuetl. My wtlrkcrs'insurancc carrier antl Sxrlicy number arc: <br />-.3,-/* 2A <br />Itrlicy <br />-l <br />ccrtity thtl in the Jrcrlormance of thc work lirr which this Jrcrmit is issucd. I shall nol cmpltty any lrcrson in any manncr <br />ol'Calililrnia, anrl agrce that if I shoukl beconrc subjccl to theso as lo bcconrc subjcct to thc workers'contJrcnsation laws <br />wrlrkcrs' conrpcnsation prlvisiotts of Scclion -17fi) of tltc I-alxlr Crxle, I shall, lirrthwith contply with thosc pr<lvisitlns. <br />WARNIN(): [jailure to sccurc wgrkcrs' conlpcnsation c()vcragc is unlawlirl. and shatl suhjcct an employer ttl criminal pnaltics and <br />civil lincs up to onc hurtdrcd thrlusand rltllars ($1fi)'Ofi)t. in <br />Scction -1076 of thc Latxlr Ctxlc. intcrcsl and attorncy's t'ccs. <br />aridition to thc cttsl ttf crlmJrcnsation. damagcs as providcd ftlr thc <br />F <br />I hcrchy all'irnr undcr pcnalty ol'pcrjury lhat I ant liccnrcd uttrlc-r prtlvision 9 (comnrcncing with Scctkrn 7000) of Division J <br />6f thc Busincss and Prul'essions Code, and my liccnse is in t'ull tirrcc arxl cll'cct. <br />I-iccnsc .L o 727 <br />CONSTRUCTION LENDING AGENCY <br />I hcrcby allirm under Fnalty of lErjury that ttrc irum.rnr"tim hnding agcncy for thc Jrcrfomncc of lhc work for which lhis lmit is <br />issued (Ss. 1097, Civ. C.). <br />knder's Name: <br />a <br />l.endcr's Addrcss: <br />APPLICANT DECI.,ARATION <br />I hcreby all-rnr under Jrcnalty of pcrjury onc ol'thc lilllowing dcclarations: <br />Dcmolition Pcrmits-Asbcstos Notification Fcdcral Rcgulations 1'titlc 40, Part6) <br />-Rcqurcd <br />Lrttcr of Nrltllicatkln <br />_l cerrily that the l'ctlcralrcgulations rcgruding ashcstos rcnxrval arc nol applicablc to lhis prtlject. <br />6**,that I havc rcad this application ard stalc thal lhc atxrvc inlirrrttatiolt <br />rlrdinanccs and Statc Laws rclalLrg to huilding ctlnstructitln.authorizc <br />atxrvc mcnlioncd propcflY ltrr <br />Applicant or Agent <br />d_. <br />Penrritee nanre <br />is crlrtccl. I agrcc ttl comPlY <br />r reprcscntalivcs of this CitY <br />with all City and CourttY <br />and county ttl cntcr uJxrn lhc <br />l. <br />u^", '//- /?-/7 <br />*,",, //^ /?-f