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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcrchy allirm undcr lrcmlty of pcrjury that I m crcmpl fmm lhc C(rtrlrack)s' I-iccnrc Lrw tor thc lilllowinS rca$tn (Scc.7031.5 - <br />Busincss arxl Prol'cssion Codc): Any City or C'ounly which rcquirc$ a Jrmit lo c('trslnrcl. allcr. improvc. dcmolish or Tpair ily <br />struc(urc. lrior lo ils issure, also rcquircs thc applicanl lbr such fEmil kr lilc a sigrcd stalcmnl thal hc or s]rc ir liccnsd pursuanl <br />t() thc pruvisions of tlE Conlractor's Licensd [lw (Chaptcr 9. Commcncing wlh Setion 7Ux) of Division -1 of thc Busircss and <br />PrufcsskrnsCodc)orthathcorshciscrcmpllhmliomandthcbasisforlhcallcgcdcxcmplion. AnyviolalionofScction?03l.5byany <br />applicant lirr a lEmit subjccts the applicatrt k, a civil pcnalty of n(rl morc lhan fivc hundrcd dollils ($50$). 'o,. <br />YLUI <br />". u*n", of th" JroJErty. or my employes with wagcs as thcir solc comlrcnsalion, will do Ihc wffk arr.l ltr slrctw is n(rt <br />intcdq! orotlercdforslc(5(.7044,BusincssmdP(rfcssionsc(xlc:'IhcG)nlracl(tr'sl-iccnscLawdocsnotapplytoanovrcrof <br />thc JtrolEny wlf,, huilds or ir{a)rcs thc6n. .nd who d(Es such w)rk him$clf or hcrrclf ()r thnrugh hir or hcr own cmploy@s. <br />provdcd lhst such impRrwnts rc ilrt intcnlql or ollcrca.l ti)r sah. It, h)wcvcr. lhc huilling or imJnrvcmnt is $ll wilhin (tnc ]4d <br />o[c\)mphthn. the Owrcr Buiucr will harc thc bunlen of pn]ving thd hc or shc dil nil buiLl or imJerw thc ImJEly tirr lhc purFr* of <br />sab). <br />_1, as owmr of thc JnrlEny. amcxclusively contracting with liccnscd conlrncloN l(, construct lhc pft)jccl (Ss. 7044, Busincss <br />arrl hrrlbsshnCode:ThcContretor'sLicenscLawd@snotopplytoanowrcrofprolrcnywhobuildsorimprovcsthcrcon, <br />and who conlraclslorsuchprojelswilhaContEck)(s)liccnscdpunuanllothcCotrlracktr'sLiccnsckw). <br />-l <br />am cxcmpt undcr Setion-, B. &LC. li[this rcas(tn. <br />,*. . r (-tq-Zo r ,t o*)( 7C (+^+,'- <br />IYOB4E&LCOIIPINSAIIQN <br />DECLARATION <br />I hcrcby alTirm under penalty of pcrjury onc of lhe fbllowinS dcclarations: <br />khrr"r*f *iff rrinrainaCcrtit-rcatcofConsnttosclf-lnsurclbrworkcrs comlrcnsatiur,as lrcvidcdti)rhySccti(]n.l7u)oflhc <br />Lalx)r C(xlc, l'or thc lrcrtbrMcc of the wo* for which thc pcmil is issucd. <br />_l hrvc nnd will maintain workcrs' compcnsalion insuraNc, as rcquircd by Sccli(ln .17fi) of thc Lahor Cqlc, for thc pcrtomEncc of <br />the work for which this lEmit is issucd. My workcrs' cr)nrpensrti(tn insuraNc caricr afil lxrlicy numhcr uc: <br />Policy Numhcr: Expircs: <br />_l ccnify that in thc pcrlilrmancc of thc work for which thi$ pcrmit is issucrl, I shall mrt cmpl(ry any pcrson in any manncr <br />v) ns h lrccomc suhjel to lhc wo]kqs' compcnsation laws of Calilirnria. and atrcc th{t if I should hcc()me suhF-{t lo llE <br />wortcrs'er)mpcnsalionprcvisionsofScclionl?00ofthcLahorCulc, lshrll. lbrlhwilhlr)mplywilhtlxrrcprcvisions. <br />WARNING: Failurc to *curc workers'compcnsation qlvcrugc is unlswlul. and shall suhjccl an cntpkrycr t, crimiul lEnaltics atrd <br />crvil fincs up to onc hundrcd lhoused dollars (Sl00,Ux)), in addili(il k) lhc cosl ol comlrcnsulion. danugcs as Jtr)vidcd for l],1 <br />- <br />.1 <br />ol' thc Busincss and Prot'essions Codc, and my liccnsc is in litll tirrcc anrl cl'tcct. <br />Liccnsc Class: Liccnsc Numhcr: <br />CONSTRUCTTON LENDING AGENCY <br />I hcrchy alfum undcr JEnalty of lErjury that thcrc is a constructbn lending agcncy for thc Jrrfirrmrec of the wrrk for which lhis Imit i3 <br />issucrl (Se. .1097, Civ. C.). <br />lrndcr's Nam: <br />I-cnrlcr's Atltlrcss: <br />APPLICANT DECLARATION <br />I krchy aflinn undcr pcnalty of perjury onc o[ the tirlkrwing dcclaratiruts: <br />Dcrnolition Pennits-Asbcstos Notit'icalion Fcdcral Rcgulations ('l'itlc 40. Parl6) <br />,-Rcquircd [-ct tcr of Notilication <br />_l ccrtily that thc l'cdcral rcgulations rcgarding asbcst()s rcnx)valilrc nol a;rplicahlc to this projcct. <br />&f,.\n,ly that I havc rcild this application and statc that thc ah)vc inlirrnrtlion is con'ccl. I agrcc lo cotnply <br />rcprcscnlativcs ()f this City <br />with all City arrd Courrty <br />and C()unty to cnlcr upott tltcordinanccs antt Stalc [,aws <br />abovc nrcntioncd p()pcrty <br />Applicarrt or Agent <br />Itcnrrilcc nanrc (nrinl):X- P,""D4ni h A tvTt <br />I -?-o lq <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 Sheathinq <br />Shear Wall <br />Framing <br />lnsulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />[\Iasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />, ,-1t / <br />FINAL t 2_/1 '*/ /7 r 'L\TL/oq <br />Certificate of <br />Notes, Remarks, Etc <br />+