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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 Iation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsu !ation/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 />I <br />FINAL ?/qdz,J^,lle.. <br />Certificate of Occu <br />Notes, Remarks, Etc.I <br />OWNER BUILDER DELCARATION <br />I lrcrcby nttrm uDdcr Fnalty of Frjury that I am cxcmpt from lhc c(rntrackfs' Liccnsc [iw l(rr thc tirlkrwing rca*rn (Se.70.]1.5 <br />Ilusincss atul Prolbssiotr C(xlc): Any City or CouDty which rcquircs a lErmil k) conslruct. altcr. improvc. dcmlish or rcpair uny <br />stnrclurc, prior lo its issuancc, also rcquircs lhc apJrlicatrt for such IErmil h tilc a sig[cd slalcrcnt thal hc or shc is liccnsd pursuant <br />k) lhc pruvisi(rns of thc Contrackr.'s Liccnscd llw (Chaplcr 9, C(rmmcncing wilh Scction 7000 (rf Divisi(rn J of lhc Blsincss and <br />ProfcssiotrsC(xlc)orthathcorshciscxcmptthcrcliomandthchasislirrthcallcgedercmption. AnyviolationofScctiu?0.ll.5byany <br />applicant for d pcrmit suhjet$ rhc applicant b r civil pcnalty of not m(,rc than fivc hundrcd dollils ($5U)). <br />_1, as owncr of'lhc pmpcrty, or nry cmployccs with wagcs as thcir solc comgrcnsation, will do thc work and thc struclurc is nol <br />intcrxlcd or oll'crcd lirr salc (Sec'.7044, Business and Prof'cssiuns CrxJc: Thc Contracl()r's [.iccnsc Law does not apply lo an owncr of <br />lhc pn)pcrty who builds or improvcs thcreon, arxJ who docs such wrlrk himself or hcrsclf or lhrough his rlr hcr own empklyccs. <br />provitlcd that such impnrverncnts arc mrt intcndcd or oll'crcrl tbr sah. ll, lrowcvcr, the buikling or impnrvcnrcnt is solJ within ()nc yciu <br />ol'complction. thc Owncr Buildcr will lurvc the burden of proving that lrc or shc did not buikl or improvc thc pnrpcrty for thc purposc ol' <br />salc). <br />_1, as owncr ol'tltc property, anr cxclusivcly cr>ntracting with liccnscd conlracto$ t() construct thc projcct (Scc. 7U4, Busincss <br />arxl hrrlbssirn Ctxlc: Thc C<lntractor's Liccnsc Law drrcs not apply to an owncr of proJrcrty who builds or improvcs thcrcon, <br />and who c()ntracts trlr such pnrjccts with a Contractor(s) licenscd pursuant to thc Contractor's Liccnsc Law). <br />-Iamc.xcnrptundcrScctitln-'B.&P.C.lbrthisrcastrn. <br />f 1..'nar. <br />TVORKERS' CO[\I PENSATION <br />DECLARATTON <br />I hcrcby atTirm unrlcr Jrcnalty ol'Jrcrjury one of thc' tolklwing dcclarations: <br />_l have and will maintain a Certilicatc of Conscnt lo Scll'-lnsurc tirr wrlrkcrs' conrJrcnsati()n, as pnrvidcd lirr by Section 3700 of thc <br />l-atxlr Ctxlc. lilr thc Jrcrlbrmancc ol'thc work tor which thc Jrcrmit is issucd. <br />l nuu"and will maintain workcrs' compcnsation insurancc, as rcquircd by Sccrion J700 of the lahor Corlc. tbr rhc pcrlirrmarrce of <br />the work tilr which this prmit is issuctl. My workcrs' comlrcnsation insurancc carricr arxl Jxrlicy numbcr arc: <br />t\I!l"oe\Policy <br />_-l ccrtity that in thc pcrtrlrmancc ol'thc work lilr which this prmit is issucd, I shall not cmploy any lrcrson in anytnanncr <br />so as to bcconrc sub.jcct to thc workcrs' comgrcnsation laws of Calilirrnia, and agrcc that if I shoukl bccomc suhjcct to thc <br />workers' conrpcnsation provisions ol'Scction 3700 of thc Lahlr CrxJc. I shall, tbrthwith comply with thosc provisions. <br />IVARNING: Failurc to sccurc workcrs' comJrcnsation covcragc is unlawful, and shall subicct an cmpkrycr to siminal Jrcnaltics and <br />eivil lincs up lo onc hundrcd tlxrusand dollars ($lm,Uru). in adrlition to the cosl ol'comJrcnsation, damages as providcd lor rli <br />1Scction .1076 thc [-akrr CtxJc, intcrcst and <br />I <br />I hcrcby affirnr undcr Jrcnalty of pcrjury that I am liccnrcd Chaptcr 9 (conrnrcncing with <br />ol' thc Busittcss and Prof'cssions Corlc, arxl my liccnsc is in full filrcc anJ cft'crct. <br />z'' <br />[.iccnsc Io Nunrhcr: <br />W <br />I hcrchy aflirm uodcr lEMlty of Frjury Ihat Ihcrc is s c(rnslruction lcndirg agency for thc Frformncc of lhc work for which this Jrcmit is <br />issucd (Scc. .1097, Civ. C.). <br />kndcr's Namc: <br />I.cndcr's Adtlrcss: <br />APPLICANT DECLARATION <br />I hcrcty allirm unrlcr Jrcnalty of pcrjury onc of thc lirlkrwing rleclarations: <br />Dcmolition Permits-Asbcstos Notification Federal Rcgulations (Titlc 40, Part6) <br />_Requ ircd Lcttcr of N<ltilication <br />_l ccrtily that thc l'cdcral rcgulutions rcgarding asbcslos rcmoval arc not applicablc to this projcct./W I ccrtify that I have read this application anl statc that thc abovc infirrmation is corrcct. I aprcc to comply with all City and County <br />rlrdinances and Statc Laws rclating to huilding constnrclion, and hcrchy autlxrrizc reprcscntalivcs of this City and County to cntcr <br />ahovc rncntkrnctl pnrpcrty lirr <br />.tplllicarrt or Agcnl <br />Pentrilee nanle <br />t"y 7ur) .l'Divisi,n 'l <br />I <br />7o <br />Flarr n9,-n7 -2n1q <br />(f, r -.fl <br />,/