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BUILDING- INSPECTOR RECORD (-') SITE.WORK DATE ID/SIG.COMMENTS OWNITR II U ILDI.:R DIiI,CARATION I hereby affrrrm under penalty of perjury that I am exempt from the C'ontractors' License law for the following reason (Sec.7031.5 IJusiness and Profession Code): Any City or County which requires a pcrmil lo construct, alter, improve. dernolish or repair any slructure, prior to its issuance. also requires the applicant lbr such pernrit to file a signed slaternent that he or she is licensed pursuant to the pmvisions of thc Conlracror's l,icensed taw (Chaprer 9, Commcncing with Section 70fi) of Division 3 of thi Business and Professions Code) or that he or she is exempt thereltom and the basis tbr the alleged exemption. Any violation of Section 7031.5 by any applicant for a pcrmit subjects thc applicant to a civil penalty of not nnre than five hundred dollars ($stXl). _1, as owner of thc property, or my employecs with wages as thcir sole compen.sation, willdo the work and the stnrcturc is rnt intendcd or oflerctl for salc (Sec'.7O44, Busincss and Profcssions Code: Thc Contractor's Licensc Law does not apply to an owner of the prcperty who builds or improves thereoru and who does such work himself or hcrself or through his or her own employees. provided that such improverrcnts are not intended orollcred for salc. Il. however. the buiEing or inproverrcnt is soH within one year of completiorL lhc Owncr Buikbr will havc thc burdcn of proving lhat he or she tlid not buill or improve the propcrty for thc purposc of sale). _1, as owner of the property, am exclusively contracting with licensed contracloni to conslruct tlr projcct (Sec. 7044, Business arxl Prolbsskln Code: The C<lntractor's License Law does not apply to an owner of property who builds or improves thercon. and who contracts for such projects with a Contractor(s) licensed pursuant to the Contractor's License Law). _l anrexempt under .Section_, R. & P.C. lbr this reason. I)ate: WORKI{)RS' COM PENSATION DECLARATION I hcreby aflirm under grcnahy of perjury one of the following declarations: _l have ard will maintain a Ccrtificate of Consent to Selt:-lnsure for workers' comgrcnsation, as provided for by Section 3700 of thc f-atgr{nOe, for the Jrcrformance of the work for which rhe prmit is Lssued.,/ 1l have and will maintain workers' compensation insurance, as required by Section 3700 of thc Labor Code, for lhc pcrformance of thc this permit is workcrs' compensation insurancc carricr and policy numbcr are: ( rL "-. Policy t\-I 1,,- [- _l certify that in thc pcrformance of thc work for which this permit is Lssuerl, I shall not cmploy any pcrson in any manncr so as to bcconrc subject worliers' comlrcnsation to the workers'compensalion laws of California. and agrcc that if I strould bccomc subject to the provisions of Section 3700 of the Labor Codc, I shall,forthwith comply with and shall subject an thosc provisions. WARNING: Failure to secure workers'compensation coverdge is unlawful.employer to and civil fines up to onc hundred thousand dollars ($l addition to the cost of the Seclion Y':W""and attorney's I hcrcby aflirm under pcnalty of perjury that I am licensed under provision of Chaptcr 9 (cornnrencing with Section 7fin) of Division 3 of the Business and Profcssions Code, and my license is in full force and cffc'ct. E-L( o License Class: License /o Lqbt( c(. CONSTRI.)CTION I,I.:NDING AGI.]NCY I hercby atfrm under pcnalty of perjury that thcre is a construction lending agency for tlre pcrformarrce of the work for which this permit ls issucd (Scc. 3097, Civ. C.). trndcr's Nanrc: [.ender's Address: APPLICANT DECLARATION I trrcby affrmr under penalty of perjury onc of the following declarations: Denplition Permits-Asbestos Notification Federal Regulations (Title 40, Part6) -Required lrtter of Notification are not applicable to this project, with all City antl County and County to enter upon the abovc mcntioncd propcrty t'or Applicant or Agcnt Prnnilee nanre ne ,z o Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf Ioor/Ve nUl n su latio n Roof Sheathinq Shear Wall Framinq lnsulation/Enerov Drvwall Ext./lnt. Lath Brown Coat [vlasonry Pool Fence T-Bar Handicap Req. Deputv Final Report Enoineer Final Report Flood Zone Certif I I ,t FINAL il tq(l't/-t>flvry7 7 Certificate of Occupancy t Notes, Remarks, Etc. Rev. 0B-07-2015 I ( oarc: n-[T- Lct (-nnlrnclnr' /I