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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I I hcrcby aftirm undcr penalty of per.yury that I am cxempt from thc Contractors' Licensc law for thc following reason (Sec.7031.5 Busincss and Profcssion Code): Any City or County which requires a pcrmit lo construct, allcr. improvc. dcmolish or repair any structure. prior to its issuarrcc, also rcquircs thc applicant for such pcrmit to filc a signed stalemcnt that hc or she is liccnsed pursuant to thc provisions of the Contractor's Liccnscd Law (Chaplcr 9, Cornmencing with Section 7000 of Division 3 of thc Business and Protbssions Codc) or that he or she is cxcmpt therefrom and lhe basis for thc allcgcd exemption. Any violation of Section 7031.5 by any applicant for a pcrmit subjcrts thc applicant to a civil pcnalty of not morc than fivc hundred dollars ($5001. __1. as owncr of thc propcrty, or my enrployccs with wagcs as thcir solc compcnsalion, will do thc work and thc structurc is ttot intcndcd oroffcrcd for salc (Scc.7044, Busincss and Prol'essions Codc: Thc Contraclor's Liccnsc law does not apply to an ownerof thc prcfrcrty who builds or improves thcrcon. and who dcrcs such work hirnself or hcrself or through his or hcr own employccs, providcd that such imlnovenrcnts arc not intcndcd oroflbrcd for sah. lf. howcrcr. thc building or inproverrcnt is sold within onc )reir of cornplction, thc Owncr Buihcr will havc ttrc burden of proving that hc or shc did not build or irnprove thc property for thc purynsc of salc). ._1, as owncr of the propcrty. am exclusivcly contracting with liccnscd contraclom to construct thc proj<rt (Scc. 7W. Busincss and Prrofesskrn Codc: Thc Contractor's License Law does not apply to an owner of propcrty who builds or intprovcs thcrcon. and who contracts for such projccts with a Contracto(s) liccnscd pursuant to thc Contractor's Licensc hw). -l am exempt undcr Scction-, B. & P.C. for this rea.son. I)ate:0wnen- WORKER.S' COM PENSATION DECLAITATION I hcreby affirm under pcnalty of Srrjury onc of the following declaralions: _lhavcandwill nuintainaCertificateofConscnttoSclf-lnsurcfrrrworkcrs'contpensation.as providcdforbySection3T00ofthe Labor (bdc. for thc performancc of thc wo* for which the pcrmit is issued. _l have and will maintain workers'conllrcnsation insurance. as rcquired byScclion 3700 of the l-abor Code, for the pcrformance of thc work for which this pcrmit is issuod. My workcrs' compensalion insurance carricr and plicy numbcr arc: Policy Numbcr: Expires: _l ccrlify thar in thc perfbrrnarce of the work for which this prnrit is issued. I shall not cnploy any pcrson in any manncr so as lo bccomc subjcct to thc workcrs' comJrcnsation laws of Calitbrnia, and agrcc that if I should beconr subjcct to thc ' workcrs' comlrcnsation provisions of Scction 3700 of the labor Codc. I shall. forthwith comply with thosc provisions. WARNING: Failurc to sccurc workcrs' compcnsation coveragc is unlawful, and shall subjcct an employcr lo criminal Jrcnaltics and civil fincs up lo onc hundrcd thousand dollars ($1ffi.000). in of darnagcs as providcd for thc Scction 3076 of the *Tr Codc. intercst / r / zozc) and atlorrrcy's I ):tl r':lt NECLARATION I hcrcby affirm undcr penalty of Srcrjury that I am liccnscd under provision of Chaptcr 9 (comnrencing with Sc'ction 7000) of Division 3 of thc Busincss and Professions Codc. ard nry licensc is in full forcc and effcct. 3 Lf,I L7 Licensc I)nlr.I o W I hcrcby affEm uftlcr Fnslty of Frjury thrr thm is I consruction lcnding agercy for lhe lErforllmc of lhe work for whhh this pqmil is isscd (Se.3097, Civ. C.). lrndcr's Name: [-cndcr's Addrcss: A PPLICANT DT'CLARATION I hcrc'by affimr undcr pcnalty of perjury one of the following dcclarations: Dcmolition Pcrmits-Asbcstos Notification Fcderal Rcgulations (Titlc 40, Part6) -Required lrttcr of Notification -_l ccrtify that lhc fcdcral rcgulations rcgarding asbcslos rcnrovalarc not applicablc to this projcct. _l ccnify that I have read this application and statc lhc ahrvc with all City arrd County and County to cnter ugrn theordinances and Statc laws relating to abovc nrntioned property for Applic:rnl or Agenl Pernritee nanre v\,L Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf Ioor/VenVl nsu lation Roof Sheathinq Shear Wall Framinq Insulation/Energy Drywall Ext./lnt. Lath Brown Coat [Masonrv Pool Fence T-Bar Handicap Req. Deputv Final Report Engineer Final Report Flood Zone Certif . I FINAL ll l-7 -00 DA'trY:7 Certificate of Occupancv Notes, Remarks, Etc Rev. 08-07 -201 5 ! ,,,", ll /s/zozo