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BUILDING- INSPECTOR RECORD SITE.WORK DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION I hcrcby affirm undcr penalty of JErjury that I m erempr fmm thc Conlracton' Liccnsc liw for thc followin8 rcasn (Scc.?o-l 1.5 Busincss urxl Profcssion Codc): Any City or County which rcquircs a Jrcrnil to conslruct. altcr. inprovc. dcitolish or. rlir any struclurc. prior lo its issuancc, ulso requires thc opplicanl for such Frmit to filc I signcd statemnt thal hc or she is liccnsd pursuanl to Ihe pmvisions of thc Contractor's Licctr*d kw (Chapler 9. Commcncing wilh Section 70U) of Division 3 of thc Busincss rnd Prcfcssions Codc) or lhot he or shc is cxcmpt thcrcfrom ond thc hasis for thc allcgcd cxcrrption. Any viohlion of Sstion 70.1 I .5 by an, applicanlforuFrmilsubjelslhc upplicantloacivilpcnallyofrolmrcthanfivchundrcddollars($5(x)). _1. as owncr of the property. or my empk)yees with wagcs as thcir sole conrpcnsalion. willdo lhc work atd thc stnrcturc is txrl intendcd or ()fl'crcd for sale (Sec.7B4. Busincss and hofcssions Codc: The Contractor's Liccnsc Law docs nol apply to an owncr of the prcJrcrty who builds or improvcs thcrctrn. and who d<lcs such work himself or hcrsclf'<tr through his or hcr own cnrployccs. providcd that such irnprovements arc not intended or ollbrcd for sale. lf. howcvcr. thc huilding or itnprovctncnl is sold within onc ycar of complctiorr. thc Owncr Buildcr will havc thc burdcn of proving lhat hc or she did not buikl or improvc thc proprly for thc pur1nrc of sale). vLl. as owncr of thc proFrcrty. am exclusivcly contracting with licensed conlractors lo construct the pr<lject (Scc. 7U4. Business and hofcssbn Code: The Contraclor's License Law docs not apply lo an owncr of proJrcrty who builds or improvcs lhercott. and who conlracts for such projects with a Contractor(s) liccnsed pursuant lo lhe Contractor's Liccnse Law). _l arn excnrpt undcr B. & P.C. lirr this rcilson. tlrrn"r,)(Date: l vl l)1,:('1,,\R,\'l'l0N I hereby affirm under penalty of prjury one of the following dcclarations: _I have and will maintain a Certificate of Consent to Sclf-lnsure for workers' compcnsation. as provided for by Section 37fi) of the l.abor Code. for thc performancc of the work for which the perrrrit is issucd. _l havc and will maintain workers'comJrensation insurancc. as required by Section 3700 of the labor Codc. for the performance of the work for which this permit is issucd. My workers' compcnsation insurancc carricr and plicy numbcr arc: Carrier: Policy Nunrber: Expircs: _5!ecttify that in the perfornmncc ol'thc work for which this perrnit is issucd. I shall rtot cmploy any pcrson in any lnatltlcr so as to hcconrc subjcct to thc workcrs'conrpensation laws of (-'alifornia. and agrcc thal if I should bcconrc suhjccl to thc workcrs' comlrcnsation provisions o[.Scction 3700 of thc Lltxrr Codc. I shall. forthrvith cornply with thosc provisions. WARNING: Failure to secure workers'compensation covcragc is unlau'ful. and shall subjcct an ctttJlloyer to crirninal pcnaltics and civil fincs up to onc hundrcd thousand dollars ($lm.mO). in addition to thc cost o[conrpcrtsalion. dattmgcs as providc'cl for the Section 3076 of the Latnr Codc. I I hercby allirnr undcr penalty of pcrjury that I arn liccnscd undcr provision of ChaJrtcr 9 (ctuttnrcncing with Sectiott 7firu) of Division 3 of the Busincss and Profcssions Codc. and my licensc is in full ltrrcc and cffcct. Liccnse Class: Liccnse Nuntbcr: Date:_Conlmclor: W I hercby aflirm undcr lEnalty of perjury that therc k a constructhn lcnding s8ercy for the pcrforromc of thc work for which this Jrcmil is issucd (Scc. 3(x)7. Civ. C.). L4ndcr's Nlmc: lrnder's Adtlrcss: APPI ICANT DECLARA'TION I trcreby alfirm undcr pcnalty of Jrcrjury one of the following dcclarations: Demolition Pcrmits-Asbcstos Notification Fcdcral Regulations (Titlc 40. Parl6) -Rcquired Lcttcr of Notificalion -l ccrtify that tlrc fcderal rcgulslions rcgarding asbcstos rcmval arc nol applicshlc to lhis pmjcct. I -l ccrtify that I have rcad lhis applicstion snd state thal thc ahlvc infomtion ii coE(|. I agre ro comply with all Cily and Counly ordinares and Stotc kss rclating to building construction. ilxl hcrcby authorizc rcprcsnt&livcs of this City ond County lo cnls ufnn lhc abovc nrcntioncd pr()pcrly tbr inspcctirlrr # ,rr". ,772r f tlApplicnnt or Agertt ^.fr tl Permltee nome (e,iil): F 'L ,+-,J .t\ +-'l 4 .f'd ^/ / Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/Venvl nsu Iation Roof Sheathins Shear Wall Framinq lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat Masonrv Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif FINAL Certificate of Occupancv Notes, Remarks, Etc. - u vl* "*", % f ut lt ).