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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 />S u bf loo r/Ve nt/l n s u Iation
<br />Roof Sheathing
<br />Shear Wall t/,7 \
<br />Framing flrzFttlSlzr RLY fI /
<br />Insu lation/Energy tl \,,
<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 />Enqineer Final Report
<br />Flood Zone Certif
<br />//.-,\
<br />FINAL 6/F,/zt F,utsl /
<br />Certificate of Occu
<br />Notes, Remarks, Etc.
<br />-t
<br />OWNER BUILDER DELCARATION
<br />I hcrcby atllrm undcr pcnalty of Frjury that I am cxcmpl liom lhc ContractoB' LiLus Law I(,t thc l'(tll(twin8 rcasD (Se.?031.5
<br />Busirrcss aul Pflrfc$sion C(xlc): Any City or Counly which rcquircs a prmit kr consIruct. altcr. intpnrvc. dcmolish or rcpair any
<br />stnrcture, pfr)r lo its issuancc, also rcquircs thc applicant fi)r such lrmit to filc a signcd slalcmot lhat hc (rr shc is liccnsd Pusuant
<br />to thc prcvisi()ns ol llrc Coilrack r's Liccnscd ljw (Chaptcr 9, Commcncing with Sccti()n 70([ of Divisiol 3 (tf thc Busincss and
<br />Pr)tbssion$Codc)orthathcorshciscxcmptthcrcliomandlhcbasisforthc.llcgcdcxcmption. AnyviolationofScctionT03l.5byany
<br />applicant li,r a pcrmil suhje-ts the npplicanl to a civil pcnahy of Dol more lhan fivc hun&cd dollds (5500),
<br />_l,as owncrofthcpropcrty.ormycmployccswithwagcsasthcirsoleconrpcnsalion,willdothcworkandthcstrus*turcisnol
<br />intcndcd or oll'crcd lilr salc (Scc.7044, Busincss and Prof'cssions Codc: Thc Contractor's Liccnse Law docs not apply lo an owner of
<br />thc pn)perty who builds or improvcs tlrcrcon. and who drrcs such work himsclf or hcrsclf or thnrugh his or hcr own cmployccs.
<br />pnrvidcd that such impnrvcrncnts arc not urtcndcd or oltcrcd lirr sah. Il, howcvcr, thc buikJing or impnrvcnrcnt is sokl within onc yciu
<br />ol'complctiolr, thc Owncr Buildcr will havc thc burdcn ol'proving that hc or shc did not build or imprrtvc thc pnrpcrty lor thc purpr:;e ol'
<br />sah).
<br />_1, as owncr of thc propcrty, am cxclusively conlracting with liccnscrl conlractors lo conslruct thc project (Scc. 7M4, Busittess
<br />arxl [totbssion Codc: Thc Contractor's Liccrrsc Law tlocs not apply to an owner ol'prtrSrcrty who builds or improves thercon.
<br />and who contracls lor such projccts with a Contractor(s) liccnsctl pursuant to the Contractor's Licensc Law).
<br />-IamexcmptundcrScctitln-'B.&P.C.forthisrcastrn.
<br />Date:Owner:
<br />wonxgns' contpexs
<br />DECLARi\TION
<br />I hcrcby alf irm undcr Jrcnalty of 1*-rjury onc of thc lirlkrwing tlcclarations:
<br />_l have and will maintain a Ccrtilicatc of Conselrt to Scll-lnsurc lilr workcrs' comJrcnsation, as provided lirr by Scction 1700 of thc
<br />Latxrr Crxlc, tirr thc pcrlirrmance ol'lhc work lor which thc Jrcrmit is issuctl.
<br />_l havc antl will maintain workcrs' comJrcnsation insurancc. as rctluired hy Scct ion 3700 of thc Lahor Codc, lbr thc lrcrlirrmancc ol'
<br />thc work lirr which this pcrmit is issucd. My wrlrkcrs' compcnsation insurancc carricr arxl Jxrlicy number arc:
<br />a
<br />_l ccrtily that in lhc pcrlilrmancc ol'thc wrlrk lirr which this pcrrnrt is issucd, I shall not cntpkry anylrcrs()n in any mantrcr
<br />so as to becomc suhjcct to thc workcrs' conrJrcnsation laws of Calilirrnia. and agrec that if I shluld bccomc suhjcct to tlrc
<br />wrlrkcrs' compcnsation provisions of Section J700 of thc Lahlr Crxlc, I shall, torthwith c<lmply with ttxrsc pnrvisions.
<br />WARNTNG: Failurc to sccurc wurkcrs' comJrcnsatiotr covcragc is unlawlirl, and shall sub.icct an cmpkrycr to criminal Jrcnaltics artd
<br />civil lrncs up to ouc hundrcd thousanrl dollars ($100,0m), in addition to the cost of comJrcnsation, damagcs as providcd tor thc
<br />attorncy's fccs.
<br />I, ICENS I.]D (]0 NTR,\('TO R
<br />DECLAITATION
<br />I hcreby allrrnr undcr pcnalty of perjury that I am liccnscd undcr provision of Chaplcr 9 (commcncing with Scction 7U)()) of fision 3
<br />ol' thc Busincss and Pnlf'cssions Codc, and my liccrtsc is in lull filrcc and clhct.
<br />,^*,",, ' E1/€LHfiEmEL /Ngaefal€ Co,
<br />policy*u,n"r. - Iy,Ol h)OOOOCbZalt Expircs:t /r/.-
<br />q?
<br />o,," *fzro/z t
<br />Liccrrsc o a
<br />a
<br />W
<br />I hcrcby allirm undcr Jrcnalty of pcrjury that lherc is a construction lcnding sgcrey li,r the pcrf<nmc of thc worl f(rr which this lsmit is
<br />issucd (Se. 3097, Civ. C.).
<br />kn,lcr's Nam:
<br />[rndcr's Adrlrcss:
<br />APPLICANT DECLARATION
<br />I hcrchy allinn undcr Jrcnalty of Jrcrjury ortc ol'thc tirlkrwing dcclarations:
<br />Dcnxrlition Pcrmits-Asbcstos Notil'ication Fcdcral Rcgulations (Titlc 40, Part6)
<br />_Rcqu ircd lrttcr of Notilication
<br />-l
<br />cc.tily that thc lbdcral rc$rlalioN rcgarding lsbcstos rcfr)val iuc not applicablc t, thi$ prrjcct.
<br />Ch ccnili lhat I havc rcad this applicrlion arl slatc that thc atnvc informli()n is coret. I alre k, (tmply with all City and County
<br />irdina&cs and Stalc hws rclntiry t(, huilding construclion, aul hercby authoria rclrcscnlativcs of this City and County lo cntcr uJx)n thc
<br />atxrvc mcntioncd proJrcrty ftrr
<br />3
<br />Applicant or Agent
<br />Penrritee nanle rrt,
<br />nq-n7 -2n 1 q
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