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BUILDING. !NSPECTOR RECORD SITE.WORK DATE !D/SIG COMMENTS OWNER BUTLDER DELCARATION I hercbl- allirm und6 penait) of perjury that I m exempt F,onr the Contraclo6' Liceroe Larv for the folklving rca{n (Se.70l 1.5 llusinss aod Protbssion Code): Any City or County which requirG a pmit to conslruct, alto. improve, dmolish or repair any struclure. prirrr to ils issuace. alsc requird lhe applicmt for such pemit to tile a signcd statmenl that he or she is liceNed pmudt ro the provisions of thc Contractor's Licensed law (Chaptq 9. Commencing with S(troo 7000 of Division 3 of thc Busins rd ProfessionsCodeiorthatheorsheisexemptthqelromMdtheb6isfortheallegedexonption. AnyviolationofS<tion703l.5byany applicant lor . pflnit subj(ts the applicant to a civil penalty ofnot more than five hundred dollars ($500) -- i, a orvnq ofthe pmlErty. or my employc wilh rvagc ru lhcir sole compcnsation. sill do thc work ild the structue is not intmded oroffcrcdforsale(Se.T044.BusinessodProfssionsCode: TheContractor'sl-icffieLawdoesnotapplyloanoMerof lhcpmpql) whobuildsorimprovcthq@d.ilduhodo6suchworkhimselforhoselforthroughhisorhoormemploycs. providcd that such imprcvqnots dc not intmded oroffrel for elc. If. howdq. lhe building or improvml is rld rvilhin one )s ofcompletion. the Oums Uuilds will have the budm ofproving thal he or she did not build or improve the prcpqty for the purposof slc). _.l.aso\wsoirhepropmy.ancrclusivelycontractingrvithlicenscdcontraclorstoconsrudthcprejet(Scc.7044.U6in6 and F\ofesronCode:TheContractor'sLicertsc[-awdocsnotapplytomownsofpropcrtywhobuildsorimprovesthscrn, and who contracts for such projects with a Contracto(s) licosed puEumt lo lhe Contractor's Liceme Larv). -l m excmpt undq Scction-, B. & P.C. for this r6on. Dnlc: WORKERS' ('O]\IPENSA'IION DECI,ARATION I hcrcb) alTlrrn undcr pcnalty of pu jury one ofthe lolkrrving declaratirxrs: _-.1havemdrvillmaintainaCenificateofcoNottoSelf-lnsureforwork6 compematron.a providedforbySelion3700oflhe Labor Codc. lirr lhe pofonnmce of lhe work for which the pmit is isued. *"[and *,ill maintain uorkers'by S(lion .1700 of lhe Labor Code. for thc pqfomacc of fcr which this pmnit is rvorkqs'cmis ud ,*,",,fu Lrg1|ifu5 Expircs: I shall not mploy any person in any mmnc so m to beccme subjcct to the workm'compensation larvs ofCalifomia. ild agrcc that ifl should become subject to the wolliqs' con4)msation provisions ofSetion 3700 ofthc Labor Codc. I shall. fonhwith comply with those provisions. WARNINGT Fhrlure lo secure workss'cornpsalion coverage is unlau'ful. md shall subjcct m qnployq to qiminal tmltie and civil fines up to one hun&ed thousd dollm ($100.000).the cost ion.for the Secli(rn 1076 of inlcresl and athmey's fc6. I hoeby affirrn unda penahy ofperjury that I dn 9 (commmcing with Setion 7000) of Division l of the Busins md Profesions Code, md my full force md effet. I hcreby afhrrn urder penalty ofpsjury that thqe is a issued (Se. 3097. Civ. C.). ijnder's Name: lending agmcv t hc po fornrancc of thc tvtr k fur rvhich this lu nrl is APPLICANT DECLARATION I hqtb,y afEm undq poalty ofpajury one ofthc following dwluations: Demolilion Pqmits-Asbstos Notincation Fcdqsl Regulations (Title 40, Pan6) _ .,Required Lctt6 of Notification _ _-l cqtify that the fcdoal regulatiom regading abestos rmoval de not applicablc to ihis prcjst. -U(cdiff thal I have rcad this application ild slatc that the above infomdion is corcct. I agre to comply with all City and County ordinancs ilJ Slale laws rclating lo conslruclion. ild hqcby abovc nrcntioncxl prope(y for /\ppli(atrt or .^gent T-Pcr milrr namc (print): of this Cily ild lo upon the Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Subfloor/VenVl nsulation Roof Sheathinq Shear Wall Framinq lnsulation/Energy Drywall I I Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif FINAL 74b-Z0zo Ctv) Certificate of Occupancy Notes, Remarks, Etc Owncr: Lends's Addr6s: J)&t