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BUILDING- INSPECTOR RECORD SITE-WORK DATE ID/SIG.COMMENTS Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground I SLAB Floor 1 zl D&+n#Pkrh Su bf loor/Vent/l nsu lation Roof Sheathinq Shear Wall Framinq lnsu Iation/Enerqy It Drywall a ,l7t 7L DKPY,/ Ext./lnt. Lath Brown Coat J\Iasonrv Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif . I I a FINAL fifffl,fi I Certificate of Occupancy Notes, Femarkq, Etc. a ?:7 p D >n-l rAla.t c u It A+fr - It I hcrcby aftirrn undcr pcnalty of perjury that I am cxenlpt tiorn the Contractors' Liccnse [.aw for the following a rcf,son (Sec.7031.5 Busincss and Profcssion Codc): Any City or County which rcquirc$ a lrcrmit to mnslruct, altcr, improvc, dcmlish or rcpdr any slructurc. prior to its i$suancc, als rcquircs thc applicant for such Frmit to lilc u signcd slalercnt lhat hc or dE is licensd pursuat to thc pmvi$ions of lhc Conlrador's Licrnrci hw (Chaplcr 9, Commcrcing wilh Scction 7000 of Division 3 of thc Busincss dd PmfcssionsCodc)orthathcorshcisexcmptthercfromandthcbssislbrthcalhgcdexcmption. AnyviolationofseclionT03l.5byany. applicant for a Frmit subj$ts thc applicant to a civil pcnalty of noI rmrc than fivc hundrcd dollus ($50O). _1, as owncr of thc propcrty, or my crnpklyecs with wagcs as their solc conrpcnsation. willdo thc work and thc structurc is not intcndc.d or offcrcd for sale (Scc.7M4. Business and Professions Codc: Thc Contractor's Liccnse Law does not apply to an owncr of thc pnrpcrty who builds or improvcs ttrcrcon. and who docs such work hirnsclf or hcrsclf or through his or hcr own cmployces. providcd that such inrprovenrcnls are not inlcnded oroflbred for sah. If, howcvcr, thc building or improvcrnent is sold within onc year of corrpletion. thc Owncr Buildcr will have thc burdcn of proving that hc or shc did not build or improvc thc propcrry for thc pur;nsc of srh). _1. as owncr of thc propcrty. arn cxclusivcly contracting with liccnscd contraclors lo construct thc projcct (Scc. 7U4, Busincss and Professkrn Code: Thc Contractor's Liccnse Law docs not apply to an owncr of propcrty who builds or intproves thcreon. and who contracts lbr such projccts with a Contractor(s) liccnscd pursuant lo thc Conlractor's l,iccnsc [:w). -lamexcmptundcrScction-'B.&P.C.forthisrcason.Date:_0wner:_ WORKITRS' CONT I'UNSA'I'ION DFCLARA'I'ION I hcrcby atllrrn undcr pcnalty of pcrjury onc of thc following dcclarations: havc and will maintain a Certificate of Conscnt to Self-lnsure for workers' cornpensation. as provided for by Section 3700 of thc latxlr Codc. lirr the pcrf<rnnancc of the work for which the pcrmit is issucd. have and will maintain workcrs'comlrcnsation insurancc, as rcquircd by.Scction 3700 of thc labor Codc, for thc pcrformancc of thc work for which this pcrmit is issued. My workcrs' compcnsalion insurancc carricr and plicy numbcr arc: poricy N","rrr, TSOCObCfl2 ff Expircs:Jltl *u _l ccrtify that in thc pcrforrnancc of thc work for which this Jrcrmit is issucd. I shall nol cnlploy any pcrson in any manner so as to bcconrc subjcct to thc workcrs'cornpcnsalion laws of California. and agrcc lhat if I should hccome subjcct to thc workcrs' conrpcnsation provisions of Section 3700 of the Labor Codc. I shall, forthwith cornply with those provisions. WARNING: Failure to secure workers' compcnsation coverage is unlawful. and shall subjcct an employer to criminal penaltics and civil fincs up to one hundred thousand dollars (5100.000), in addition to the cost of comgrcnsation, damages as provided for the Scction 3076 of the labor Codc. interest and attorncy's fees. ,^r", {/tl I vt Appricanr: Sc*<? h|/^-a^^--- LICENSFN CONTRACTOR DT'CLARATION I hcrcby afllrrrr under Jrcnalty of prjury that I arn liccnscd undcr provision of Chapter 9 (comnrcncing with Scction 70m) of Division 3 of thc Busincss and Professions Codc. and rny liccnsc is in full forcc and cflbct. Liccnsc Nurnbcr:4a to zl r):rrc AlLtl>t W I hcrcby affirm undcr JEnalty of pcrjury thal lhcrc is I @nslructbn bndirg .gcmy for thc pcrformncc of thc work for frich this lEmit is issucd (Sa. 3097, Civ. C.). kndcr's Namc: I lxndcr's Addrcss: APPLICANT DECLARATION I hcrcby affirnr under penalty of pcrjury one of thc following dcclarations: Dcrnolition Pcrmits-Asbcstos Notification Fcderal Regulations (Titlc 40. Part6) _Rcquircd lrtter of Notification _l ccrtity that thc t'cdcral rcgulations rcgarding asbcstos rcrnovalarc not applicable to this pr<ljcct. ccrtify that I havc rcad this application and statc that thc alxrvc inlirnnation is corrccl. I agrec to conrply with all City and Counly and State Laws rclating to building constnrction. and hcrcby authorizc rcprcscntalivcs of this City and County to cntcr uJnn thc abovc nrcntioned propcrty for insJrcction Applicant or Agent f)ate: Pernrilee name (print):// ,a?kâ‚¬/2-r 7-l - I+ I (L