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BUILDING- INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNIiR Il tl ILl)tllt DI:,LCA RA'l'lON I hereby affirnr untler penalty of perjury that I anr exenrpt fronr the Contraclos' License Lrw for the following reasor) (Sec.7031.-5 llusincss arxl Prol'cssion Codc): Any City or County which rcquircs a Jrcrmit lo construct. altcr. irnprove. dcrrxrlish or repair any slructure. prior to it.s issuance. also requires the applicant tor such Jxrnril to file a signed statement ttrat lre or she ls licensed pursuanl lo thc. provisions ol' thc Contractor's l.icenscd law (Chaptcr 9. Comrnencing with Scction 7(XX) ot' Division 3 ol'thc Business and ProtcssionsCotle)orthatheorsheisexempttheretionrandtlrcbusislbrtlreallegedexenrplion. AnyviolatiouofSectionT03l.5byany appliclnt for a perrnit subjects the npplicant to il civil penllty of not rnore than live hundred dollars ($5tXt). _l. as owncr ol'thc propcrty, or tny crnpkryccs with wagcs as thcir solc compcnsation. will do thc work and thc stnrcturc i.s rrlt irrtcmletl oroffcred for sule (Sec'.7()14, Business and Pnrfcssions Codc: Tlrc Contraclor's License Ltw does nol apply to an owner of tlte pnrperty who builds or inproves thereou arxl wlto drxs such worh hinrselt'or lrerself or tlrrough his or her own employees, providcd that such imprrrvcrrcnts are not intendcd orollbrcd ltrr s.rh. Il. txrwcver. thc buikling or improvcnrnt is sold within one ycar of conpletion, tlre Owner Builder will have the hurtlcn of pnrving tlurt lle or she tlid not build or inrpnrve tlrc prcperry for llre purgrsc of sale). _1, as owner o[the property, am exclusively contracting with licenscd conlraclors to construcl tlte project (Sec. 704+, Business arrd l\ullrision Corle: The Contractor's Licerrse Law does not apply to an owner of proJrcrty who builds or improves lhcrcon. and who conlracts for such proicts with a Contractor(s) liccnscd pursuant to lhc Conlraclor's Liccnse kw). -Iantexcml)tunderSection-'B.&P.C.titrlhisreasttlt.f 1.,.,.. WORKI{RS' CO[\I PI,:NSATION DECLARATION I hcrchy allirm undcr pcnalty of perjury one of the tbllowing dcclarations: _l have rurd will maintain a Certilicate of Corrsent to Self'-lnsure for workers' conrperlsation, as pnrvided fbr by Section 3700 of the Latxrr Culc. for the performancc of the work lbr which thc pcrrnit [s issucd. _l have and will nuintain workers' conrpensation insurance, as required by Section 3700 of the l.abor Code, for lhe prerfornutrce of thc work lilr whiclr this pcrnrit is issucd. My wrlrkers' compcnsation insurancc carricr aml policy numbcr are: Policy Nunrber: lixpires: _l ccrtity that in thc pcrtbrnuncc of thc work frrr which this pcrnril is issucrl, I shall not enrpk)y any pcrson in any manncr so aslobccorrrsuhjccttothcworkcrs'conrpcnsationlawsofCalilbrnia,andagrecthrtiflshouldbccorncsubjccttothc workers' conrpensation provisions of Section 3700 of the Labor Cotlc, I sturll, forthwith conrply with thosc provisions. IVARNING: Failurc to sccurc workcrs' conlpcnsation covcr.lgc is unlawlul. antl shall subject an cntploycr to crinfnal pcnaltics and civil l'ines up to one hurrdretl thousand dollars ($l(X),(XX)). in acldition to thc cost of conlpensation. datnages as provided for the Section 3076 of the Lahor Cotte, interest and allomey's fees. I)atc: I,ICENSED (]()N'TRA(]TOR DECI,ARATIoN I hcrt'by al'lirrn undcr p-*nalty ol'pcrjury that I arn liccnscd undcr provision ol'Chaptcr 9 (cornrncncing with Scction 7000) ol'l)ivision 3 of thc Bu.sincss and Pnrl'cssions Cotlc. arxl nry liccnsc is in full firrcc and cll-cct. Liccnsc Class: Licensc Numbcr: CONSTRT'CTION I,B:NI)ING AG}:NCY I hereby atlrrm under penalty of per.jury that there is a construction hrrdfurg agency tirr the performarrce of the work tbr which this permit ls issuctl (Scc, J097, Civ. C.). l-cndcr's Nanrc: l-cndcr's Atltlrcss: APPLICANT DE(:LARATION I hereby affrnr untler penalty of perjury one of the following tleclarations: Dcnrolit ion Perrnits-Asbestos Notificat ion Federal Regulat iorrs (Title 40, Part6) _Rer1uired Lelter of Notification with all City and County and Courtty to enter uF)n ttE _l certify thut the t'ederal regulatiorrs regarding ashcslos renxlvul are n()t a;rplicable to lltis project. Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenVl n su latio n Roof Sheathinq Shear Wall Framing lnsulation/Enerqy Drywall Ext./lnt. Lath Brown Coat I\/asonrv Poo! Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif rI ^ tl f, FINAL I t)l'l/)\*+4t{7 Certificate of Occupancv lr Notes, Remarks, Etc. Rev. 0B-07-2015