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BUILDING. INSPECTOR RECORD SITE-WORK DATE ID/SIG.COMMENTS OWNER B T.IILDER DELCA RATION I hercby affirrn under pnalty of pcrjury that I am cxcmpt frorn the Contractors' License [:w for the following rcason (Scc.7031.5 Busincss arxl Profession Codc): Any City or County which rcquircs a pcrmit to construct. altcr, improve, demolish or reJrair any structure, prior to rts issuancc, also rcquircs thc applicant for such permit to filc a signcd stalcmcnt that hc or she is liccnscd pursuant to thc pnrvisions of thc Contractor's Liccnscd l-aw (Chapter 9. Commencing with Scrction 70fi) of Division 3 of the Business and Profcssions Code) or that hc or she is excnpt thercfrom and the basis for thc allcgcd cxcmption. Any violation of Scction 7031.5 by any applicant lbr a pcrrnit subjccts the applicant to a civil pcnalty of not morc than fivc hundrcd dollars ($500). -1. as owncr of the propcrty. or my employccs with wagcs as lhcir solc compcnsation. will do thc work and thc structurc is not intcnded rlr offercd for salc (Scc.7044. Busincss and Prof'cssions Codc: Thc Contraclor's Liccnse [:w does nol apply to an owncr of the propcrty who builds or improves thereon. and who does such work hirnsclf or hersclf or through his or hcr own cmployees. providcd that such improvcnrcnls arc not intcndcd oroffcrcd for sah. lf. howcver. thc buiUing or improvcnrcnt is sold wilhin onc ycar of corrphtiorl the Owncr Buildcr will have thc burdcn of proving that he or shc did not buikl or improve tlre propcrty for ttrc purynsc of sah). -1. as owncr of thc propcrty. am cxclusivcly contracting with liccnsed contractors to construct the projtxt (Sec. 7W, Busincss and Rotbssion Codc: The Contractor's License Law docs not apply to an owner of propcrty who builds or improvcs thcreon. and who contracts for such projccts with a Contracto(s) liccnsed pursuant lo thc Conlractor's Liccnse t aw). _l am cxempt under Section_ B. & P.C. for this reason. Date:_ WORKER^S' COM PENSATION Ihcrebyaffirmunderpenaltyofperjuryoncofthc,o,,o*,n,ffi _l have and will maintain a Ccrtificatc of Conscnt to Self-lnsurc for workers'compcnsation, as provided for by Section 3700 of thc Labor Code, for the pcrformance of the work for which thc pcrmit is issucd. â‚¬, n"r" and will mainrain workers' compcnsation insurarrce. as rcquired by Scclion 3700 of thc Labor Code. for rhc pcrformance of the work lor this pcrrnit is issucd. My workcrs' cornpcnsation insurancc carricr and gllicy numbcr arc: Policy t _l certity that in thc pcrformancc of thc work for which this Jrcrrrrit is issucd, I shall not employ any pcrson in any nunncr so as to bcconrc subjcct to thc workers'con{rcnsation laws and agrec thal if I should bcconrc suhject to thc shall. forthwith comply with thosc provisions. I workcrs' comJrcnsation provisions of Scction 3700 of thc [:tnr WARNIN(I: Failurc lo srccurc workcrs' cornpcnsatiorr and shall suhjcct an crnploycr to criminal pcnaltics and civrl fines up to onc hundrcd thousand dollars ($100.0m).the cost of conrpcnsation, danurges as provided for thc Section of the l-atxrr C-odc, intercst and attorrcy's fces. I hcrcby affirm undcr pcnalty of pcrjury that I am liccnscd undcr provision of Chaptcr 9 (comnrcncing with Scrtion 7Un) of Division 3 of the Busincss and Professions Code. ard my licenrc is in full force and effcrct. Liccnsc Nunrbcr:(rtSqoSO W I hcrcby affirm undcr lEnaltyof Frjury lhat thcrc is 8 construction lcnding agcrcy for thc lrcrformc of thc work for which this lsmil is issued (56. 3097. Civ. C.). l4ndcr's Nare: [.cnder's Address: APPLICA NT DIICLARATION I hcrctry afl'irm undcr penalty of pcrjury onc of the following dcclarations: DcrrurIition Perrnits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40. Parl6) Rcouircd L*ttcr of -l ccrtify that thc tbderal rcgarding asbcstos rcnnvalarc not applicablc to this propct. _l ccrtify thal I havc rcad stalc that thc ahrve infornurtion is correct. I agree to comply with all City and County I rcprcscnlativcs of this City and County to cntcr u;nn thcordinanccs ;rrrd .Siatc [-aws above rnentioncd property for IoApplicnnt or Agenl Permilce name construction, anci hcrcby authorize Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bf Ioo r/VenUI ns u I atio n Roof Sheathinq Shear Wall Framing Insulatio nlEnergy Drywall Ext./lnt. Lath Brown Coat [Masonrv Pool Fence T-Bar Handicap Req. Deputv Final Report Engineer Final Report Flood Zone Certif F!NAL l'lQ'/'O DIMth 4tr' Certificate of Occupancy Notes, Remarks, Etc. Rev. 08-07-201 5 0wner:-- Applicant:-