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BUILDING. INSPECTOR REGORD SITE.WORK DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION I I I hcrcby afl-rm under pcnalty of prjury that I am exerrpt from thc Contractors' Liccnsc [:w for thc following reason (Scc.7031.5 Busincss and Profession Code): Any City or County which rcquires a permit to construct. allcr. improve, dcmolish or rcJrair any structurc. prior to its issuancc, also rcquircs thc applicant for such pcrmit to file a signcd statcrrcnt that he or she is licensed pursuant to thc lnovisions of thc Contractor's Liccnscd Law (Chapter 9, Commencing with Section 7000 of Division 3 of the Business and Profcssions Codc) or that hc or shc is cxcmpt thcrcfrom and thc basis for thc alleged exemption. Any violation of Section 7031.5 by any applicant for apcrmit subjectsthc applicant to acivilpenaltyof not morethan fivc hundrcddollars ($500).? _1. as owncr of the propcrty, or nry cmployces with wagcs as thcir solc compcnsation. intcnded or offcrcd for sale (Scr.7044. Business and Profcsskrns Codc: Thc Contractor's License l.rrw does not apply to an owner of thc proirrty who builds or improvcs thcrcoru and who does such work himself or hcrself or through his or her own employccs. providcd that such impovcnrcnts arc not intcndcd or otTcrcd for sah. lf. howcrrr. thc buiHing or irprovcrrcnt is sold within onc ycar of comphtion. thc Owrrcr Buikler will havc thc burden of proving that lrc or she did not build or improve ttrc property for thc purgnsc of sfllc) _1, as owner of thc property, am cxclusivcly contracting with liccnscd contractors to conslruct thc projcct (Scc. 7W, Busincss and Pnrfcssion Codc: Thc Contractor's Liccnse Law docs nol apply to an owncr of prolrcrty who builds or improves thcrcon. and wh<l contracls for such projccts with a C-ontractor(s) liccnscd pursuanl to thc Contractor's Liccnse taw). -lamcxemptunderScclion-.B.&P.C.forthlsreason.__ Owner:_ WORKER,S' COM PENSATION DT'CI ARATION I hcrcby aflirrn under penalty of pcrjury onc of thc following dsclarations: _l havc and will maintain a Ccrtificatc of Consent to Sclf-lnsurc lbr workcrs' compcnsation, as providcd for by Section 37fi) of the Latxrr Codc. f<rr the perfornuncc of thc work for which thc pcrmit is issucd. _l havc and will maintain workcrs' cotnpcnsation insurance, as rcquircd by Section 3700 of thc l-abor Code. for the Jrerformance of the work lbr which this ;rcrmit is issucd. My workers' com[rcnsalion insurance carrier and grlicy numbcr are: Policv Nunrbcr: Exnircs: _l ccrtify that in the pcrfbrmancc of thc work for which this pcrrnit is issued, I shall not cnploy any pcrson in any tnanncr so as to bccomc subject to the workcrs' compcnsation laws of Califbnria. and agrce that if I should beconre subject to thc workcrs' compcnsation provisions of Scction 3700 of the labor Codc. I strall, forthwith comply with those provisions. WARNING: Failure to l*curc workcrs' compcnsation covcragc is unlawful. and shall subjcct an employer to criminal pcnaltics and l civil lines up lo onc hundrcd thousand dollars (S100.000), in to the cost of com[rcnsation. damages as provided for thc attorncy's ?t I hcrcby allinn undcr pcnalty of prjury that I arn licenscd 9 (conrmcncing with Section 7000) of Division 3 of thc tJusincss and Profcssions Codc. and nry liccnsc is in full force arxl cffcrct. [,iccnsc Date:_.1_=----__ W I hcrcby alnrm urder Fnalty of pcrjury that thcrc is r onslruction lcnding sgcrcy for thc lErturnurcc of thc work for which this ]rcrmit is issucd (Scc. 3097. Civ. C.). Lcndcr's Name: l-crrdcr's Addrcss' a A PPLI CA IYT DT'C LA RATION I trcrcby aflinn undcr penalty of pcrjury onc of thc following declarations: f)crnolition Perrnits-Asbcstos Notification Fcdcral Regulations ('l'itle 40, Part6) -Rcquircd lrttcr of Notification -l ccnify that Ihc fcdcmlregulations rcgarding asbcslos rcmvalrrc rct applicablc to this pmj6t. _l ccnify rhat I have read this application ard state that tlE atnvc infomtion is @rec|. I agr lo @trply uith all Citysnd County ordinanccs aml State [3ws rclaling lo MildinS consrrctiotr atd herclby sulhorirc repre$ntatircs of lhis City and County to enter upon the above rrrcntioncd property for Applicant or Agent Pernrilee nsnre o*", rr /t ( /zoza Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf Ioor/VenVI nsu latio n Roof Sheathinq Shear Wall Framing lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat [Vasonry Pool Fence T-Bar Handicap Req. Deputv Final Report Enqineer Final Report Flood Zone Certif I FINAL tzlslu t **K/ Certificate of Occupancy Notes, Remarks, Etc Rev. 08-07 -201 5 Date:__ o