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SITE.WORK DATE ID/SIG COMMENTS OWNI.IR B UIl,I)tlR Dtil,CARATION I hereby aflirnr under penalty of perjury that I am exempt from the Contraclors' License law for the following reason (Sec.7031.5 llusincss and Protbssion Code): Any City or County which requires a grcrmit to conslruct, alter, improve, demolish or repair any strucmre, prior ro its issuancc. also rcquires the applicant fbr such perntt to file a signed staternent that lrc or she is licensed pursuanl to the pmvisions of the Contractor's l.icensed law (Chapter 9. Comrncncing with .Section 700O of Division 3 of the Business and Professions Code) or that he or she is exenpt therefrom and the ba.sis tbr the alleged exemplion. Any violation of Section 703 I .5 by any applicant for a pennit subjects the applicant to a civil penalty o[ not more than five hundred dollars ($5001. _1. as owncr ol'thc property. or tny employees with wages as their solc compcnsation, will do the work and the stnrcture is not intemlcd or offered for sale (Scc.7U4, Busincss and hofessions Co<Ie: Thc Contraclor's License ltw docs nol apply to an owner of the property wlro builds or irprorrs theruon, anrl who rloes such work himself or herself or through his or her own employees. providcd that such improvcments are nol intended or olTercd for sale. Il. however, the building or furprovenrcnt Ls sold within one year of conrpletion, the Owncr Buildcr will have the burden of pmving that lre or she did ntrt buikl or inrprovc thc propcrry for thc purposc of sale). _1, as owner of thc propcfly, am exclusivcly contracting with liccnscd conlractoni to construcl thc project (Sec. 7044, Busincss arxl Prrolbssbn Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon. and who contracrs for such projects with a Contractor(s) licenrcd pursuanl lo lhe Contractor's Licen"se kw). -l am exempt under B. & P.C. for this reason. WORKI,:RS' C( )M PFINSATION DECLARATTON I hcreby aflirm undcr pcnalty of pcrjury onc of thc following declarations: _l have and wilt nraintain a Certilicate of Consent to Self-lnsure frrr workers' compen.sation, as prcvided for by Section 3700 of the Labor Code, for thc pcrformancc of thc work for which the pcrmit is issued. and will Section 3700 of thc [:bor Code, for the trrcrformance of_l have thc work carricr arxt plicy numbcr are: Policy _l ccrtify that in thc pcrtbrmance of thc work tbr which this pcrmit is issued, I shall not cntploy any pcrson in any manncr so as to bccornc subjcct lo thc workcrs' conrpensation laws of Califomia. and agrce that if I should bccotnc subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall, forthwith comply with tlxlsc provisions. WARNING: Fuilure to sccure workcrs' compcnsation is unlawful. and shall subjcct an employcr to criminal penalties and civil fines up to one hundred thousand dollars ($addition to the cost o[ compensation. damages as provided for the allorncy's DECLARATION I hercby allirm under penalty of perjury that I am licensed under provision of Chapter 9 (cornmencing with Section 7m0) of Division 3 of the Busincss and Professions Code, and my liccnse is in full forcc and elTect. #*o t2n36e37 t {r 3 I' CONSTRI.'CTION I,I.]NDING AGI.:NCY I hercby atlirm under Jrenalty of grerjury that thcre is a construction lendfurg agency fbr the prformarrce of the work for which this prmit is issued (.Sec. 3097, Civ. C.). lrnder's Name: hntlcr's Addrcss: APPLICANT DECLARATION I hereby affrnr under pnalty of perjury one of the following doclarations: Demolition Permits-Asbestos Notification Federal Regulations (Title 40, Part6) -Required lrtter of Notification _l certify that the federal rcgulations asbestos renrcvalare not applicable to this project. -l certify that I lurve read this ordirunces and State Laws relating to tlre atxlvc me nti()ncd propcrty li)r Applicant or Agent I'ennitee nanre thal the I -b Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf I oor/VenUl nsu latio n Roof Sheathinq Shear Wall Framinq lnsulation/Enerqv Drvwall Ext./lnt. Lath Brown Coat Jvlasonry Pool Fence T-Bar Handicap Req. Deputv Final Report Enoineer Final Report Flood Zone Certif FINAL // -/2-u LL tgu h?rugqn Certificate of Occupancy Notes, Remarks, Etc. BUILDING- INSPECTOR RECORD I Rev. 0B-07-2015 -