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SITE.WORK DATE ID/SIG.COMMENTS OWNER B UILDI.IR I)I.:LCA RATION I hereby affirnr under penalty of perjury that I am exempt fr<lm the Contractors' License Law for the following reason (Sec.7031.5 Business and Prol'ession Code): Any City or County which requires a grermit to construct, aher, improve, demolish or repair any structure, prior to its issuance. also requires the applicant for such permit to file a signed statemenl that lr or she is licenscd pursuanl to thc. provisions of the Contractor's Licensed Iaw (Chapter 9, Commencing with .Section 7fi)0 of Division 3 ol'thc Business and Prot'essions Code) or that he or she is exempt thereltom and ttre basis frrr the alleged exenrption. Any violation of Section 7031 .5 by any iyfllanr for a pcnnit subjects rhc applicanl lo a civilpennltyof not more than llvc hundred dollars ($5Ott1. W^f .}:il:li';i[[?3J;ffi:ff,?J:"':.:lHHilfli?il:$.':[fril1',:l;il:*:Lx,.,Hy,:Hffi[:J#,1.,", the prcperty who builds or improws thcroru and wtn does such work himself or herself or through his or her own employees. provided that such improvenrcnts arc mt intendcd or oll'cred for salc. Il. however. thc building or improvcrnent is sold within one ycar of conpletion, lhc Owner Builtler will have thc burden of proving that lrc or she tlid not build or improve Ore propaty ftrr thc purposc of sale). _1, asownerof the properly, amexclusivelycontracting with licensed conlraclorstoconslruct the pmject (Scc.7M4. Business alxl hofe;skrn Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon. and who contracts for such projccts with a Contracto(s) liccnsed pursuant lo the Conlraclor's Liccnsc taw). _l am under Secti.rn-,?-Owner: \t woRKaRS'('OttP}:NS < I hcreby allirm under grenalty of perjury onc of the tbllowing dcclarations: -l have and will nraintain a Certilicate of Consent to Selt'-Insure for workers' compensation, as provided for by Scction 3700 of the Labor Code, for thc Jrerforrnarrce of thc work for which thc pcrmit Ls issued. _l have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for lhe lrcrformance of thc work tbr which this permit is issued. My workers' comJrcnsation insurancc carricr ard plicy numbcr are: Policy Nunrber: Expires: fur"^ity that in the prtbrnurncc of rhe work for which thi.s grcrmit is issucd, I shall not employ any person in any manncr | # as to beconrc suhject to the workcrs' compensalion laws of Califionria. and agrcc that if I should bcconre subjcct to ttrc workers' contlrcnsation provisions of Section 3700 of the Labor Code, I shall, forthwith comply with thosc provisions. WARNING: Failurc to secure workers'compensation coveragc is unlawful, and shall subject an cmploycr to criminal penalties and civil lines up to one hundred thousand dollars ($Ifi),UXt). in addition to the cost of darnagcs as provided for thc Seclion 3076 of [-atxlr interest and attorney's fees. tl-oZc I t)t.t('t,.\ R,\1't( )N I hercby aflirm undcr pcnalty of perjury that I am licensed under provision of Chapter 9 (cornmencing with Section 70m) of Division 3 of the Business and Professions Code, and my liccnse is in full force arxl effect. t ll Liccnse Class: Liccnse Number: CONSTRI.ICTION I,ENDING AG}:NCY I hereby atlirnr under penalty of perjury that there is a construction lending ager..,*y tor the performarrce of thc work tbr which this permit is issued (.Sec. 3097, Civ. C.). lrndcr's Namc: [-cndcr's Atltlrcss: APPLICANT DECLARATION I trcreby affirm under pnalty of perjury onc of thc following doclarations: Denrolition Permits-Asbestos Notification Federal Regulations (Title 40, Part6) _Required l-etter of Notification _l certity that the federal regulations regarding asbe.slos removal are not applicable to thi.s proilct. in[ormation is correcl. I agrec lo comply ,representatives of tNs City with all City and County and County to enter upon thcautlrorize atxrvc mcnti()ncd property ltrr inspcction , Applicant or Agcnt I)errnitce nanle Datc: { Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf Ioor/VenUl ns u lati o n Roof Sheathinq Shear Wall Framing Insulation/Enerqy Drywall Ext./lnt. Lath Brown Coat Jt/asonrv Pool Fence T-Bar Handicap Req. Deputy Final Report Enqineer Final Report Flood Zone Certif. I tl-,/^ FINAL lr l(luo Dt{ v s/ Certificate of Occupancy Notps, Bemarks, Etc. Ir BUILDING. INSPECTOR RECORD t Rev. 08-07-201 5 ,'/([Vl 9 ( fYl-l-^{-ry\ 1v 4H unfD .-l>*,wsg