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BUILDING- INSPECTOR RECORD {a SITE.WORK DATE !D/SIG.COMMENTS OWNER BUILDER DEI,CARATION I hcrehy affirm undcr lEnahy of perjury that I am crcrlpt frcm lhc Conlmclors' Liccns hw for thc following rcdsn (Scc.7O:11.5 Bushrcss and Profcssion Codc): Any City or County which rcquircs a JErmit lo conslrucl. allcr, improvc. dermlish or rcpair any structurc. prior k, its issuarce. alre rcquircs thc apIrlicant for such Frmil lo lilc a signed slatcrcnl lhst hc or shc is liccnsd pursuont t, thc pmvisions of thc Contractor's Liccnmd law (Chaptcr 9. Commcncing with Scclion 7000 of Division 3 of lhc Busincss and Pmfcssi()nsCodc)orthathcorshciscxcurptthcrcfromandthcbosisforthcallcgcdcxcmplion. AnyviolationofScctionT03l.5byany applicant for a Frmit subjecls thc applicant k a civil pcnrlty of not morc lharr tivc hundrcd dollus (3500). _1. as owncr of the propcrty. or my enlployccs wilh wages as thcir sole compcnsation. will do thc work and thc stnrcturc is not intcnded or offered l'or sale (Scc.7044. Business and hofcssiorrs Codc: Thc Corrtraclor's Licensc [.aw does not apPly to an owner of thc pmpcrty who builds or improves thcrcrrn. and who docs such work hintsclf or hcrsclf or lhrough his or hcr own enlployecs. providcd thnt such improvenrents arc not intcndcd or offcrcd for salc. tf. howevcr. thc building or improvctncnt is sold within one ycar of corrrphtion. thc Owncr Builder will have thc burdcn of proving thal hc or shc did not build or inrprole thc propcrty for thc purfnscof sah). _1. as owncr of thc prr)Jrcrly. anr cxclusivety contracting with liccnscd conlraclors lo conslrucl thc projcct (Sec. 7044, Busincss and Pnrfcsskrn Coclc: Thc Contractor's Licensc Law docs nol apply to an owncr of propcrty who builds or improves thercon. and who contracts l'or such projccts with a Contract<lr(s) liccnsed ;tursuant lo thc Conlractor's Liccnse Law). _l artt B. & P.C. I hcrcby afl'irrn undcr pcnalty of pcrjury onc rtl'thc _l have antl will maintain a Certificate of Conscnt to Self-lnsurc for workers' comlrcnsation. as providcd for by Scction 3700 of thc l-ahrr Codc. for the grcrformance of thc work for which thc pcrmil is issucd. _l havc ancl will maintain workcrs' conlpensation insurance. as rcquired hy Scction 3700 of the Labor Code. for lhc pcrfonnance of the work for which this pcrnrit is issucd. My workers' compensation insurance carricr and plicy numbcr are: Policy Nunrhcr: ExPircs: - _l ccrtify that in thc;rcrfornrancc of thc work lirr which this pcrrnit is issued. I shall nol employ any person in any manncr so as to bccome suhjcct to thc workers' comJrcnsation laws of California. artd agree that if I should heconre subjcct to thc workers' conrpcnsalion provisions of Section 37fi) of thc Latnr Codc. I shall. tirrthwith cornply with thosc provisions. WARNING: Faiturc to secure workers' conlpensation coverage is unlawful. and shall subjecl an entploycr to criminal'lrcnaltics and civil fincs up lo onc hundrcd thousand dollars in addition lo lhc cosl o[ compcnsation. damages as providcd for the illtorney's I hcrcby alfirm undcr pcnalty of pcrjury lhat I arn liccnsctl undcr of Chaplcr 9 (contrrrcncirrg rvith Scction 7(XX)) tll'l)ivisiotr J of lhc Business and Profcssions Code. and nty licensc is in full lorcc and effcct. Licensc Class: Licensc Numbcr: l):rlc ('oltlr:tt'lor W I hcrcby aflirrn undcr Jrnalry ofpcrjury lhat thcrc is a consrrucrim lcnding agcncy for lhc pcrformne ofthc work for which this lErnlil is issucd (Scc. 30)7. Civ. C.). APPLICANT DECLARA'TION I trreby afiinn under pcnalty of pcrjury one of the folkrwing dcclarations: Dcrnolition Perrnits-Asbcstos Notification Fcderal Regulations (Titlc 40. Part6) -Requircd l-cttcr of Notificalion _l ccrtily that thc fcdcral rcgulations rcgarding asbcstos rcnmvalarc nol applicablc lo lhis projccl. _l ccrlify that I havc rcad this application and slalc that lhc atxn'c irttirrntatiott is corrccl. t agrc'c to with all City and County rlrdinarrccs anrl .Statc l-tws rclating to conslrucli<ln. and hcrcby authorizc rcprcsctttativcs County lo enter upon thc ahovc nrcnliorrcd propcrty lbr Applicant or Agenl Pernrilee nAme purposcs. ""%1(lcfq Set Backs \ Forms/Steel/Holdowns \?-r? -f 9 Acq Erection Pads / UFER Ground SLAB Floor Su bf loor/VenUl nsu lation Roof Sheathinq a -*sr . .O t/) Shear Wall t I Ut \,/ ah "l'!'t Framinq io //,uq ft16r0,9 (/4c Jz'rua<--/l4,LInsulation/Energv /4Drywall I ffi -/u/ffi v ) Ext./lnt. Lath 4 il uf Brown Coat I 5 lnrlcn I I t --*t.b aa tq [\Iasonry I I I UI \--=z Pool Fence T-Bar Handicap Req. Deputy Final Report Enqineer Final Report Flood Zone Certif .qcrdnlN lolalu q ) r/tr 11591J w) vl I u\ FINAL iol 3'r'l La-\r<M r vY) Certificate of Occupancv rl r \)- \ N otes,,Rem arks,rrEtc.^, /,l-I tA ,4/r/31lq lcuAlL ^ffi ) /{1fMt .^l- ln4) I