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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/Ve nVl n s u I atio n <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />Insulatio nlEnerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />N/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />/ <br />//./\ <br />FINAL lnlzr LrJ'O1 I <br />Certificate of Occu <br />Notes, Remarks, Etc. <br />I}U I I,I)I'R DI.]I,CA RATION <br />I hcrchy dmrm undcr IEntrlIy of Frjury that I er cxcmpt frenr thc Contracton' Liccnsc hw for thc following rcasn (Sc.?031.5 <br />Busincss and Profcssion Codc): Any City or County which rcquircs a pcrmit to construct. alter, impmvc, dcmlish or rcpair my <br />structurc. Jrior to its issulrcc. 8l$ rcquircs thc opplicant for such Frmit to nb a signcd statcmnt that hc or shc is liccnsd pusuant <br />to thc pmvisions of thc Controctor's Licenrcd taw (Chaptcr 9, Comncing silh Sslion 7000 of Division 3 of thc Busircss and <br />PmfcssionsCodc)orlhathcorshciscxcmpllhcrcftomsndthcbasisforthcallegcdcxcmplion. AnyviolalionofsectionT03l.5byrny <br />applicant for a pcmit subjccts the spplicant to a civil penalty of not mrc than fivc hundrcd dollus ($500). <br />_1. as owner of thc propcrty, or my cmployces with wagcs as thcir solc conrpensation. willdo thc work and thc structure is not <br />intcndcd or otfcred for sulc (.Sc.c.7044, Business and Professions Codc: Thc Contractor's Licensc Law docs not apply to an owner of <br />the proprty who builds or improvcs thcreon, and who docs such work hirnsclf or hcrsclf or through his or hcr own cmployccs, <br />providcd that such irnprovcrncnts arc not intcndcd or oflcrcd for salc. If. howcver. thc building or improverrnnl is sold within onc )aar <br />of conrphtion. thc Owncr Buildcr will have thc burdcn of proving that hc or shc did not build or improve the pmprty for the purynsc of <br />sah). <br />_1. as owncr of the propcrty, anr cxclusivcly contracting with liccnscd conlractors lo conslruct thc projcct (Sec. 7U4. Busincss <br />and hufbssion Code: 'l'he Colrtractor's Liccnse Law docs not apply to an owner of propcrty who builds or intprovcs thercon, <br />and who contracls frrr such projccts with a Conlraclor(s) Iiccnscd pursuant to lhc Conlraclor's Liccnsc Law). <br />_l arn cxcmpt undcr Scction_. B. & P.C. for this rcason. <br />f)ate:_ <br />WORKIiRS' C( }M PENSA'IION <br />Dt'CI,A ITA"I'ION <br />I hcrcby afllrrl undcr pcnalty of'pcrjury onc ol'lhc ltrllowing dcclarations: <br />_l havc and will maintain a Ccrtifrcate of Conscnt to Sclf-lnsurc for workcrs' comJrcnsation. as providcd lbr by Section 3700 of thc <br />[:bor Codc, lbr the Jrcrfornrancc of the work for which thc pcrmit is issued. <br />work <br />and will ntaintain workcrs'cornpcnsation insurancc, as rcquircd by Scction 37fi) of thc Labor Codc, for thc pcrforrtuncc of <br />tbr which this pcrnrit is issucd. My workcrs' compcnsalion insurancc carricr iurd policy numbcr iu'c: <br />poricyNr,rt*r, 5? tN €CZE QQ-? I Expircs: gl2LtZt <br />_l ccrtity that in thc pcrltrrmance of thc work f<rr which this pcrmit is issucd. I shall not crnploy any pcrson in any manncr <br />so as to bccomc subject to lhe workcrs'compcnsation laws of California. and agrce that if I should bccomc subjcct to thc <br />workcrs' compensation provisions of Section 37fi) of thc [:bor Codc. I shall. forthwith comply with thosc provisions. <br />C <br />WARNING: Failure to sccurc workers'comJrcnsation coveragc is unlawful. and shall subjcct an <br />civil I'incs up to one hundrcd thousand dollars ($100.000), <br />Scclion 3076 of the Latxlr Code. intcrest and attorncy's fccs. <br />in addition to thc cost of damagcs as provided for thc <br />I hcrcby alfirm under pcnalty of prjury that I anr liccnscd 9 (comnrcncing with Scctkrn 7000) of Division 3 <br />of thc Busincss and Profcssions Code, and nry liccnse is in full forcc <br />Liccnsccross' B Ct] LiccnscNumbcr:lotLLqa <br />0 <br />W <br />I hcrcby rllirm undcr Jrcnulty ofJrcrjury that rherc is a construction lcnding rgcncy for thc lErformncc ofthc work tt r which this Jrcrmit Ls <br />issucd (Scc. 3097, Civ. C.). <br />Lcndcr's Narne: <br />[,cndcr's Address: <br />APPLICANT DT'CI ARATION <br />I hcrcby affinn undcr pcnalty of perjury onc of thc following dcclarations: <br />Dcrnolition Pcrmits-Asbestos Notification Fedcral Rcgulations (Titlc 40, Part6) <br />-Rcquircd <br />lrttcr of Notilication <br />_l ccrtify that the fcdcralrcgulations rcgarding asbcstos removalarc not applicable to this project. <br />with all City and County <br />and County to cnter upon thc <br />abovc rncntioncd property f<lr inspcction <br />Applicant or Agent <br />Permilcc name <br />0wner:_ <br />c",,,",, 4lar*{ord \ $S. <br />to lzq [^ r conrracror:_ <br />o^", blzqlzt