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BUILDING- INSPECTOR RECORD SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcreby aftrm under Jrcnalty of Jrcrjury that I am cxcmpt fronr the Contractors' Licensc l,aw for the following rca.son (Sec.7031.5 Busincss arrd Profession Code): Any City or County which rcquires a prmit lo construct. allcr. improvc, dcmolish or re;uir alry structurc. prior to its issuance, also rcquires thc applicant for such grcrrnit to filc a signed stalemcnt that hc or she is liccnrcd pursuant to the provisions of ttre Contractor's Liccnscd Law (Chaptcr 9. Commcncing with Section 7000 of Division 3 of the Business and Profcssions Code) or that hc or shc is cxcmpt thcrcfrom and the basls for thc allcgcd excmption. Any violation of Section 7031 .5 by any applicant for a Jrcrrnit subjc'cts rhc applicant to a civil pcnalty of not more than five hundrcd dollars (5500). I _1. as owncr of thc proprty. or nry cmployccs with wages as thcir solc compcnsation. willdn thc work arxl thc su,s*turc is rxrt intcndcd or offcrcd for salc (Scc.7044. Busincss and Profcssions Codc: Thc Corrtractor's Liccttsc l,aw d<lcs not apply to an owner o[ thc proJrrty who builds or improves thcrcon. and who docs such work hinrsclf or hcrsclf or through his or her own cmployecs, providcd that such inrprovcnrcrrts arc not intcndcd orollercd lbr sale. If. howcvcr. lhc buiHing or inryrrovcnrnt is sold within onc )anr of conplctiorr, thc Owner Buildcr will have thc burdcn of proving that hc or shc did not build or intprovc thc property for ttrc purprsc of sah). -1, as owncr of thc property. amexclusively cotrtracting with liccnscd contractors to construct thc propct (Scc. 7044, Busirrcss and hofcssion Codc: Thc Contractor's Licensc Law does not apply to an owncr of propcrty who builds or improvcs thereon. and who contracts for such projects with a Contractor(s) liccnscd pursuant to the Glntractor's Liccttsc [aw). _l am cxcmpt under Sc'ction-, B. & P.C. for thls reason. Date:_ WORKERS' COMPENSATTON DECLARATION I hcrcby alfirni undcr pcnalty of pcrjury onc of thc lbllowing dcc'larations: _l havc arxl will rnaintain a Ccrtificatc of Conscnt lo Sclf-lnsurc tbr workcrs' compensation. as providcd for by Scction 3700 of thc 3700 of thc Labor Codc. for thc pcrformarce of arxl policy nurnbcr arc: Policy M _l ccrtity that in the pcrformancc of thc work for which this pcrmit is issucd. I shall not cmploy any pcrson in any nulnncr so as to bccornc subjcct workcrs' conqrcnsaliorr to thc workcrs'compcnsation laws of Califonria. and agrec that if I should bccomc subjcct to thc provisiorrs of Section Code, I shall. forthwith conrply with those pnrvisions. WARNIN(i: Failurc lo sccurc workcrs'covcragc unlawful. and shall subjcct an crnploycr to criminal pcnaltics and civil fincs up to one hundrcd thousand dollars irr to the cost of compcnsation. danragcs as providcd for the Scction 3076 of thc l-:bor Codc, interest and fecs. ,,r"10-zg,'aff^ I hcrcby atllrrn undcr pcnalty of pcrjury that I arn liccnscd undcr of thc Busincss and hofcssions Code, and my liccnsc is in full 9 (cornrncncing with Ser"-tion 7m0) of Division 3 aml eftect. License Nunrbcr: q5o7 q? o*",Jo - z8- 4c I hcrcby affirm undcr pcnalty of perjury that thcrc is a construction issucd (Scc. 3097. Civ. C.). agcrrcy for the performrurce of thc work for which this permit is lrnder's Namc: knder's Addrcss: APPLICANT NECLARATION I hcrcby affirm undcr pcnalty of pcrjury onc of thc following dcclarations: Donolition Pcrmits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40. Part6) _Rcquircd L*ttcr of Notification -l ccrrify Ihol thc fedcml rcgulations rcgarding osbcstos rcm)valare ret {pplic{blc to this pmjNt. lAJccrrify rlar I havc rcad this applicotion ild statc thot tlE abovc informtion is corccl. I agre to comply with all City and Counly brdinan@s and Statc bws rclilting to building constructiotr ud hcrcby outhoria rcprcsntstivcs of this City and Crunty to cntcr utDn the above rncnlioned propcrty for .ztr-UQ Applicant or Agenl Pernritee na[ne (orint):rre 9a \rv1 tAa Q, )e a Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bf loor/VenVl ns u latio n Roof Sheathino t/ '/(" '.k)7 wro(//l yrlve,Y( Shear Wall Framinq lnsulatio nlEnergy Drywall Ext./lnt. Lath Brown Coat ltlasonry Pool Fence T-Bar Handicap Req Deputv Final Report Engineer Final Report Flood Zone Certif It.t , tt FINAL llll6l'Lo upq@r 7,W Certificate of Occu Notes, Remarks, Etc. Rev. 08-07 -201 5