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BUILDING. INSPECTOR RECORD SITE-WORK DATE ID/SIG.COMMENTS OWNI]R BUILI)ER DEL('ARATION I hereby aflirm unda penally of psjury lhat I an erempl fiom lhe ConlractoB' Licqrse La$ for the follosing reasn (Se.70-11.5 llusincss and Profssion Codc): Any City or Counly which requircs a peirnil lo conslruct. alto'. irnprove. dernolish or repair ily stnrcture. prior lo its issuance. also requirG the applicant for such pennit lo file a signed statonml lhal he or she is licosed puGumt lo the $ovisions ofthe Contraclor's Licensed Larv (Chapler 9. Comrnencing wilh Section 7000 ofDivision.l ofthe Business and Profe$ionsCode)orthalheotsheiseremptthqefiomandtheb6isfortheallcgedcxernpthn. AnyliolitionofsationT03l.5byany applicantforapennitsubjelsthe applicsnttoacivilpenahyofnotnrorelhanfivehundreddollars($5d0). . - .- -1. as orvner of I he profE ly. or my etnployees rvilh rvages m lhcir mle compmsation. \1ill do the $ork ard lhc struclurc is nol intsded oroflsedforsle(Sa.7044.Busin$sandl'rofsionsCodei lheContractor'sl,icmse I-a$do6notappl]toano$nqof lheprcfrty rvhotxrildsorinprovelhson.ildwhodo6suchuofthimselforherselforlhroulrhhisorhero$nempl()]-e6. providedthatsuch inprcvmmtstrenotintodedoroflq-erlforsle. If hosevs.thebuildingorimporoncnlissoldNithinone,@ ofcomplelion. the Olvner Buildq will havc the burdot ofproving thal he or shc did nol build or irnpmve the ptolEly for the pu4ns of sle ). _1. rs orvner ofthe prop6ty, dn cxclusively contraclin8 rl ilh liccnsed conlraclors to constnrct lhe projed (Se. 70.,14. []usins and I'rofssion Codc: The Conlraclor's l-icense [,aw do6 not applv to an os'ner ofpropeny who builds or irnproles thcreon. and who contracts for such prcjects *ith a Contractorls) licenscd pursuaill 1o lhe ('onlractor's License l-a\\ ). -l m exernpt undr Sstion--. a. & P.C. for this re6on Date: __ __ Osner: woRKttRs' cot\tPENsA'iloN DECT,AR,{'tION I hereby affirnr under penalty ofpojury onc ofthe follorvirg dclaralions: -l have md will maintain a Cetlificate of Consent to Self-lnsure for worko's cornpens.tion. s provided for by S(tion -1700 of the txbor Code. for thc pqfonnance of the q,ork for rvhich the pmit is isued. I hare and rvill maintain workers' cornlxnsalion insurance. m required by S(tion -1700 ofthe Labor Code, for lhe prq fonnmcc of thc sork for shich lhis pcrrnit is issucrl.coillllcnsali()n insrrrancc can'icr anrl lxrlicr numtrcr uc: Carier: l'olicy Nurnber:l;\l)ir es: _l cenify lhal in the perforrnance ofthc rvork for rvhich this pumit is issucd. I shall nol ernphy anl person in any nrannt'r s d to becorne subj(t to the $ork(s'composalion la$s ofcalifomia. and agre that ifl should trcone subi*t to thc worko's' comparsalion provisions ofSection 3700 ofthe l-atnr Code, I shall. lbnhwith comply with lhos provisions. WARNINC: Failure lo seure sorkers'corn;rcnsalion co\emge is unlarvful. and shall suhjecl an onplolcr h oiminal Frrmltie and civil lines up lo one huildred thousand dollars in aLldition to lhe cosl of conrpensalion. danrages as prorided fcl the Section 1076 of rhe LaU)r Code. intsd and atlorey I DF,CT.ARATION I hocby aflinn undo pmalty of pqjury that I an lico*d under govisfun of Chapls 9 (commmcing $'ith S*tion 7000) of Division 3 of lhe Busin6s md Prof6sions Code, and my licflsc is in full force and effat. Licenseclass: i *f'Z ,,,", //zl fzo[{;*;,Xru. qa >rf CONS'TRUC'TION LENDTNG AGENCY I hereby affitm under penalty of psjury lhal thse is a conslruction lending agency for the psformmce ofthe work for Nhich this pcrmit is issued (S(. -1097, Civ. C.). Lender's Narne: - l-ends s Addr6s: AI'PLICANT DECLARAl'ION I hoeby affinr unde penalty of perjury onc of the folbrving delarations: Dcrnolition Pqrnils-Asbestos Notification Fedtral Regulations ('l itle 40, Parl6 ) Rcquired Ldtd of Nolifi cation I cqtify that thc fedeal regulations rcgrding astrstos rernolal are n(x applicahle h this prcjet. -l cdify that I hale read this application ordiDanccs and Slale [-aws above trolioned prolEtly for Applicanl or Agent Sign{ltrre Permite tr{mc (pritrl): thc Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloor/VenUl nsulation Roof Sheathinq Shear Wall Framing lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif FINAL Certificate of Occupancy Notes, Remarks, Etc. l)ale G//tD/+t'/