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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG-COMMENTS OWNER BUILDER DELCARATION I hcrcby aflirm undcr Jrcnally oi JErjury :har I .m cxcmpt from thc Conlractors' Liccnsc liw for thc following rcasn (Sft.7031.5 Busiocss aul Prolbssion Cfile): Any City or County which rcquircs a tsmil k) crtnstruct. alts. improvc. demrlish or rcpair any structuc. prirr li) ils issuancc, also rcquircs lhc applicant for such [Ermil lo Iilc a signcd slatcmnl that hc or slE is licensd pursuail to the pruvisions of thc G)ntrrctor's Liccnscd trw (Chaptcr 9, Commcncing with SR-tion 70fi) of Division -l of thc Busircss and Prlfcssions Codc) or thdt hc (r shc is ercmpt thcrcfrom and thc basis for thc alleScd crcmption. Any violation of Scction 703 1.5 by any applicant for a lEmit subjccts thc apJtlicant to a civil pemlly of nol morc than livc hundrcd dollars (Ssm). _1, as owncr of thc propcrty. or my cmployccs with wagcs as lhcir solc compcnsation, will do thc work atkl the slrurturc is not tntcndcd or olTcrcd tirr salc (Sc,c.7044, Business and Prol'cssions Codc: 'fhc Contractor's Licensc Law docs not apply to an ttwncr of thc pnrpcrty who huilds or impnrvcs thcrcon. and who tltrcs such work himsclf rtr hcrself rlr through his tlr hcr tlwn cmployces, providcd that such improvcnrcnts arc not intcndcd rlr olfcrcd lor sale. If, howcvcr, thc buikJing or improvcrnctrt is sold within onc year ol'conqrhtion, thc Owncr Buiklcr will havc thc burdcn ol'proving that he or slrc rlid not bui[ or improve the propcrty for thc pulTnse ol' salc). _1, asowncrol'thc pnrpcrly, amcxclusivelyconlracting with liccnscd contractorstocottstruct lhc pntject (Scc. 7044, Business arxl Pnllbssion Codc: The Contractor's l-iccnse Law dtrcs mrl apply tr> an owrtcr of propcrty who huilds or intprtlvcs thcrcon, and who conlracts frrr such pnrjccts with a Contractor(s) liccnscd pursuant to thc Contractor's Liccttsc Law). -IamcxemptundcrScction-,B.&P,C.Ibrthisrcason'Owner: wonrrns' colvtpgNsA DECL/IBAIION I hcrcby affrm undcr pcmlty of ptjury orc of lhc following delsrations: / _lhavcaBlwill mintaineCcnifrcatcofconsnttoSclf-lnsurelbrvorks'comlEnsation,as lf,ovidcdforbySstion.lT00ofthc lirr thc prcrlilrmancc ol'thc work tilr which thc Jrcrmit Ls issucd. Wir will maintain workcrs' c()mpcnsation insurattcc. as rcquircd hy Scctiolt -17fi) of thc Labor Codc, firr thc pcrfirrmancc of and prlicy number arc:pernrit is issucd. t^\4y workers' compcnsation insurance _l ccrtity that in thc pcrftlrmancc ol'thc work lirr which this Jrcrmit is issued, I shall not employ any frcrson in any matrner so as to bccomc subjcct to thc workcrs' compcnsation laws of Calililrnia, and agrcc that if I shrtuld hccttnrc subjcct to thc workcrs' comJrcnsation provisions of Scction -]700 of thc Lahlr CrxJc, I shall, tilrthwith comply with thosc provisitltts.a WARNING: I'ailurc to s)curc workcrs' comJrcnsation coveragc civil lincs up lo onc hundrcd thousand tlollars (S100,fiX)), in is unlawful, arrrl shall subpct an cnrpkrycr to criminal pcnaltics and addition to thc cost of contJrcnsation, rlamagcs as providcd tirr thc intcrcst and attorncy's lbcs. DECLARATION I hcrcby al'trm undcr penalty of pcrjury that I am liccns,ctl undcr provision of Chaptcr 9 (commencing with Scction 7m0) of Division 3 of thc Busincss and Prol'cssions Cotlc, arxl my licensc is in tull firrcc and cltcct. 4 C I hcrcby afllrm undcr pcnalty of prjury that tlterc is a construction issucd (Sec. .1097, Civ. C.). l,cndcr's Namc: agcncy pcrfirrmancc ol'lhe work lirr which this Jrgmit is [.cndcr's Address:I APPLICANT DECLARATION I hcrcby atl-rnr undcr grcnalty of pcrjury onc of thc lbllowing rleclarations: Dcmolition Pcrmits-Asbcstos Notilication Fedcral Rcgulations (Titlc 40, Paa6) -Rctluircd [rttcr of Notilication w":;':: ;,,:: fctlcralrcgulatiolrs rcgarding asbcstos rcmoval arc n()t applicablc to this pntjcct. rcad this application and state that thc ahrvc intbrmation is corrcct. I agree to comply with all City and Counly ordinanccs and State laws rclating to buikling entcr uJxln thc tirr insJrcction purF)scs. rcprcscntativcs ()f this city 7p Set Backs Forms/Stee!/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenVI nsu latio n Roof Sheathinq Shear Wall Framinq lnsulation/Enerqy Drvwall Ext./lnt. Lath Brown Coat Masonry Pool Fence ,( T-Bar Handicap Req. Deputy Final Report Enqineer Final Report Flood Zone Certif I I a FINAL ll lcd 1p DAryV' Certificate of Occupancy I Notes, Remarks, Etc. , lf !I ..- Porr nP.-n7 -2O I q I