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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 Ioor/VenUI ns u latio n <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsu lation/Enerqy <br />Drvwall <br />Ext./lnt. Lath <br />Brown Coat <br />lMasonry <br />Pool Fence <br />T-Bar \ <br />Handicap Req. <br />Deputy Final Report / <br />Engineer Final Report <br />Flood Zone Certif. <br />t/z1 <br />-LFINAL <br />Certificate of Occu <br />Notes, Remarks, Etc. <br />/ <br /><-'a <br />I hcreby offrrn under pcnalty of;rrjury that I m cxcmpt from thc Contrrctom' Lhcn* liw fo. thc following rcamn (Ss.?031.5 <br />Busincss and Prcfcssiotr Cftlc): Any City or County which rcquircs a fErmit 1o @nstruct, altcl improrc, dcmlish or rcpair my <br />structurc. prior to its issuancc, olso rcguircs the appltmt for such lEmit to lilc a signcd stalcmtrt that lrc or s]rc ir licensed puzuut <br />1o thc previsions of thc Contrrctor's Liccnscd taw (Chaplcr 9. Commncing with Sstion 7000 of Division 3 of thc Busiress and ' <br />PmfcssionsCodc)orthathcorsheiscxcmptthercfremsndttEbmisforlhcallcgcdcxcnwion. AnyviolationofSstionT03l.5byany <br />applicant for a pcrmit subj$ts thc applicant to a civil pcnalty of not mrc than fivc hundred dolles ($50O). <br />-1. <br />as owncr of thc propcrty.or my cmployccs with wagcs as thcir solc cornpcnsation. willdo thc work and the structurc is not <br />intcnded or offcrcd for sale (Scc.7044. Business and Professions Codc: Thc Contraclor's Liccnse Law docs not apply t<l an owncr of <br />thc propcrly who builds or improves thcrcon. and who docs such work hirnsclf or hcrsclf or through his or hcr own employecs. <br />provided that such improvcmcnts arc not intcnded or offercd for sah. If, howcver. thc building or improvcrncnt is soh within onc ycar <br />of complction. thc Owncr Builder will havc thc burden of proving that hc or she did not build or improvc the pnrprly for thc purposc of <br />sale). <br />_1. as owncr of thc propcrty, arn exclusivcly contracting with liccnscd contraclors lo conslruct thc project (Sec. 7W, Business <br />and Prrolcssion Codc: Thc Conlractor's Liccnsc Law docs not apply lo an owncr of propcrty who builds or improvcs thcrcon. <br />and who conlracts for such projccts with a Contractor(s) liccnscd pursuant to thc Contractor's Liccnse l.aw). <br />_l am cxcrnpl undcr B. & P.C. lbr this reason. <br />Date: Owner: <br />WORKERS' COMPENSATION <br />DF'CLARATION <br />I hcrcby affrm under pcnalty of pcrjury one of the following dcclarations: <br />havcandwill rnaintainaCertificateofConscnttoScll'-lnsurcforworkcrs'conrlrcnsation.as providedforbyScction3T00ofthe <br />t2bor Codc. for thc pcrforroncc of thc work for which thc pcrmit i! issucd. <br />$ havc and will maintain workers' comlEnsation insurorcc. ss rcquircd by Scclion 3700 ofthc bbor Codc, for thc pcrtorrc of <br />Ihc work for which this pcmit is issucd. My workcrs' compcnsation insurancc cmier and lrclicy numbcr uc:*b/z ot-t Fuyrol <br />Poricy *"rr*r. ?OA 5584 Expires:/on2 /zr <br />_l certify that in thc pcrforrnance of thc work for which this pcrnrit is issucd. I shall not cmploy any pcrson in any manner <br />so as lo bccome subjcct to thc workers' compcnsation laws of California, und agrce that if I should bcconre subject to thc <br />workers' compensation provisions of Scction 3700 of the Lrbor Codc. I shall. forthwith cornply with thosc provisions. <br />WARNING: Failurc to sccurc workers'compcnsation covcrage is unlawful. and shall subjcct an employcr to criminal pcnaltics and <br />lbr thc <br />LICF'NSED CONTRACTOR <br />DECL/IRATI0N <br />I hcrcby affirm under pcnalry of perjury rhat I arn licenscd under provision of Chaptcr 9 (comnrcncing with Section 7000) of Division 3 <br />of thc Busincss and Profcssions Code. and nry liccnsc is in full lbrcc and effcct. <br />-/O 7rss" 7 <br />Contraclor:o <br />7na <br />CONSTRUCTION LENDING AGENCY <br />I hcrcby affrm undcryEnalty of pcrjury that thw is a @nstruction lending agcmy for thc Jrcrforrorcc of thc work for which this pcrmit is <br />issucd (Sec. 3g)7. Civ. C.). <br />lrndcr's Namc: <br />Lcndcr's Addrcss: <br />APPLICANT DECLARATION <br />I hcrcby alilnrr undcr penalty of pcrjury one of thc following dcclarations: <br />Dcrrrolition Permits-Asbestos Notification Fcdcral Rcgulations (Titlc 40, Part6) <br />-Requircd <br />l.ctter of Notification <br />-l <br />ccrtify that thc federal rcgulations rcgruding asbcstos renrovalare not applicablc to this projcct. <br />ccrtily that I havc rcad this application with all City and County <br />and County to cnter upon thcordinanccs and Statc Laws rclating to <br />above mcntioncd propcrty for inspcction <br />or Agent <br />IDernritee nanre Ct a- <br />o,r", oo/o?/zt <br />civil fincs up to ollc hundrcd thousand <br />Scction 3076 of the l;rhrr Codc.intercst <br />_License