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SITE.WORK DATE 'iD/slG.COMMENTS <br />Set Backs <br />Forms/Steel/Holdowns /-5'2{lfe,ltfi hd6 <br />Erection Pads <br />UFER Ground A <br />SLAB Floor <br />Su bf Ioor/VenVl nsu Iation <br />Roof Sheathing <br />Shear Wall <br />Framing <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Jt/asonry ilt ) <br />Pool Fence f./?d{a-m rud6 <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif. <br />I I NL --^ r, <br />FINAL l\lylu s{ililfr,wa \ <br />Certificate of Occupancy I I <br />Notes, Remarks, Etc <br />a <br />I hcrcby aflirm undcr JEnally of pcrjury lhat I m cxcmpt ln)m lhc G)nlraclos' Liccnsc llw l(rr thc folkrwing rca$n (Scc.70-11.5 <br />Busincss anl Prolbssion CGlc): Atry City or County which rcquircs a lrcrmit lo conslrucl. allcr, improvc. dcmolish or rcpair any <br />structurc, Fior to ils issuancc, also rcquircs thc applicant for such Jrmil m lih a sigrcd statcmnl lhat hc or shc is licrnsd pusuant <br />lo lhc pft)visions of thc Conlrackrr's Liccnsd kw (Chaptcr 9. Commcncing with Scction 70{X) of Division -J of thc Busincss and <br />Pn)lbssions Codc) or that hc or shc is cxcmpt thcrcliom and thc hasis lirr thc allcgcd cxemption. Any violation of Scction 701 1.5 by any <br />lirr a pcrmit subjccts thc applicant to a civil pcnalty of not murc than fivc hundrcd dollars ($.5m). <br />t <br />as owncr <lf thc propcrty. or nry cmployccs with wagcs.rs thcir solc compcnsation, will do thc work ard thc structurc is not <br />intcndcd or oflcred frrr salc (Scc.7(X4, Busincss and Pnlfbssions Crxle: Thc Contractor's Liccnse Law docs not apply to an owncr of <br />thc pn)pcrty who builds or impnrvcs thcrcon, and who d<rcs such work himself or hersclf or through his or hcr own cmpkryccs, <br />providcd that such impnlvcrncnts arc mlt intcrxlcd or oll'crcrl tirr sah. It, howcvcr. thc buikling or improvcnrnt is sokJ within onc ycar <br />ol'comphtkrn, the Owncr Builtlcr will havc tlrc burdcn of prlving that hc or she did not builJ or impnrvc thc pnrpcrry lbr tlrc purJxlsc of <br />salc). <br />_1. as ownL'r of thc proF-rty. amcxclusivcly contracting with liccnscd conlract()rs to construct thc pnrjcct (Scc. JOd{, [ttsillsss <br />anrl ltulbssrln Codc: The Contraclor's l-icense Law docs not apply lo an owncr of proJrcrty who builds or improvcs thcrcon, <br />and who contracts lirr such pro.iccls with a Contraclor(s) liccnscd pursuant to thc Ct>ntractor's Liccnsc [-aw). <br />_l amcxcmpt undcr Scction_, B. & P.C. lirr this rcason. <br />I <br />DECLARATION <br />I hcrcby allirm under Jrcnalty ol'Jrcrjury onc of the following dcclarations: <br />_l havc and will maintain a Ccrlilicatc of Conscnt to Sclt'-lnsurc tor workcrs' compcnsation, as providcd for by Scction -1700 of thc <br />Lahrr Ctx-le, for thc pcrformancc of thc work fbr which the pcrmit Ls issucd. <br />-l <br />have and will maintain workcrs' compcnsation insurancc, as rcquircd by Scction 3700 of thc Labor Codc, titr thc pcrformancc of <br />thc wrlrk lilr which this pcrmit is issucd. My workcrs' compcnsation insurancc carrier and g>licy numbcr arc: <br />Numbcr: Expircs: <br />ccrtily that in the Jrcrlirrrnancc ol'thc wrlrk tilr which this Jrcrnrit is issucd. I shall not cnrpkry any frcrs()n in any manncr <br />Io hccomc subjcct to lhc workcrs'comJrcnsation laws of Calilirrnia, and agrec that if I should bccomc subjcct to thc <br />workcrs' comJrcnsati<ln provisions ot'Scction 17ffi of thc [:hlr Gxlc. I shall, tilrthwrth comply with thosc prlvisions. <br />fVARNtNG: Failurc to sccurc workcrs' compensation covcragc is unlawlirl. and shall suh.jcct an to criminal Jrcnaltics and <br />r:ivil lincs up lo onc hundrcrl thousand dollars cost of rlamagcs as providcd tor thc <br />Scctiorr 1076 of thc Lahrr Crilc, intcrcst and <br />o^rc, 12 '/o' ZO <br />I hcrchy allirm undcr Jrcnalty ot'prjury that I am licenrcd of Chaptcr 9 (commcncing with Scction 7UX)) of Division -] <br />ot' thc Busincss and Prol'cssiorts Codc, and my liccnsc is in tirll tirrcc and ctl'cct. <br />Liccnsc Class: Liccnsc Numbcr: <br />I)alc: <br />W <br />I hcrcby atfum undcr frcnalty of Frjury that thsc is a custruction bnding agency for the Jrcrlbrmncc of thc vork for which this tsmit is <br />issucd (Ss. J097, Civ. C.). <br />kn,lcr's Nam: <br />I-cntlcr's Addrcss: <br />APPLICANT DECLARATION <br />I hcrchy allirm untlcr pnalty ol'Jrcrjury onc of thc tirllowing dcclarations: <br />Dcrrxrlitiorr Permits-Asbcstos Notification Federal Regulations ('l'itlc 40, Part6) <br />-Rcquircd <br />lrttcr ol' Notilication <br />ccrtily that the t'erlcralrcgulalions rcgarding asbcstos rcn'xrvalarc nol applicablc to this projcct. <br />that I havc rcad this application and statc that thc atxrvc with all City and County <br />and County to cnter uJxrn lhcand Statc <br />ahlvc mcntioncd <br />or /2, <br />nantc <br />and <br />€-hl 41- <br />.r-(c) <br />\ <br />BUILDING. INSPECTOR RECORD <br />Elorr n9.-n-7 -)n { q