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BUILDING. INSPECTOR RECORD SITE-WORK DATE ID/SIG.COMMENTS OWNER BI.IILDER DELCARATION I hcreby affirrn under penalty of pcrjury that I am excmpt from thc Contractors' Licensc [.aw for the following reason (Sec.7031.5 Business and Profcssion Codc): Any City or County which rcquircs a pcrmit to construct, alter. improvc, dcmolish or rcJrair any structure, prior to its issuance, also rcquircs thc applicant for such pcrmit to file a signcd stalemcnt that he or shc ls liccnscd pursuant to ttrc provisions of thc Contractor's Liccnscd Law (Chaptcr 9, Commcncing with Scction 7000 of Division 3 of thc Busincss and Profcssions Code) or that hc or shc is exempt thercfrom and the basis for the allcged cxemption. Any violation of Section 7031.5 by any lpplicant for a pcrmit subjccts thc applicant to a civil penalty of not morc than five hundrcd dollars ($5001. _1. as owncr of the propcrty.or nry enrployccs with wages as thcir solc compcnsalion. willdo thc work and thc structurc is rnt intendcd or offcrcd for salc (Sec.7044, Busincss and hofessions Codc: The Contractor's Licensc law does not apply to an owncr of the proprty whcr builds or improves thcrcon and who docs such work himsclf or hcrself or through his or hcr own employees. providcd that such imlnovcnrcnts are nol intendccl or offcrcd for sah. lf. howcrrcr. thc buiHing or inrprovcnnnt is sold within onc ycar of complcti<ln, thc Owncr Buihcr will havc thc burdcn of pmving that hc or she did not build or improvc thc proprry for thc purynsc of sale). _1. as owner of thc prolrerty, amcxclusively contracting with liccnscd conlractors lo construct thc projcrt (Sec. 7(X4, Busincss and Profcssion Codc: The Contractor's License Law docs not apply lo an owncr of propcrty who builds or improvcs thercon, and who contracts for such projccts with a Contractor(s) liccnsed pursuant to thc Contractor's License Law). -l am cxenlpt under Section-. B. & P.C. for this rcason. I )alt'. ( )rr lrcr. WORKERS' CONIPENSATION DECI ARATION I hcrcby affirm undcr pcnalty of pcrjury onc of thc following dc''claralions: --l havc and will maintain a Ccrtificate of Conscnt to Sclf-lnsurc for workcrs'compensation. as providcd for byScction 3700 of thc l-^abor Codc. for thc ;rcrforrnancc of thc work for which the prmit is issued. #havc and work lbr will maintain 3700 of thc [:bor Codc. for the grcrformance of this ard grlicy nurnbcr are: t (Policy _l ccrrify that in thc prlirrnmncc of thc work for which this is issued. I shall not crnpkly any person in any rurnncr should bcconr subject to thcso as lo bccomc subject to tlrc workers'compcnsation laws agrcc that if I workcrs' compensation provisions of Section 3700 of thc forthwith c-omply with thosc provisions. WARNING: Failure to liccurc workers' contpcnsation and shall subject an cmploycr to criminal penaltics and compcnsation. danuagcs as providcd for thccivil fincs up to one huntlred thousand dollars cost of Section 3076 of thc l-;rbor Codc. intcrcsl and attorney's fces. o ? DT'CI ARATION I hcrcby affirnr undcr pcnalty of pcrjury that I am liccnscd under provision of Chaptcr 9 (comnrencing with Section 7000) of Division 3 of thc Business and Profcssions Code. and my liccnsc is in full force and effcct. Liccrrse Date: c3a Nurrrhcr: (oSQorn 07 AvP l\L) W I hcrcby aflirm urdcr pnalty of lErjury that thcrc is a construction lcnding agcrcy for thc pcrfollllmc of thc work for which this lEmit is issucd (Se. 3097. Civ. C.). l-cndcr's Nanrc: [,cndcr's Addrcss: APPI ICANT NECI ARATION I tucby affinn undcr pcnalty of pcrjury onc of the following dcclarations: Dcmolition Pcrmits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40. Part6) Reouircd _l ccrtify that thc fcdcral rcgarding asbcstos rcnxrvalarc not a;l;rlicable lo this projcct. _l ccrtily that I havc rcad this and statc that thc abovc inlbrmation is corrcct. I agrce to comply rreprescntatives of this city wilh all City and Counly and County to cntcr upon thcordinances and Statc laws abovc nrntioncd proprly for Applicnnt or Agent Perntilee construction, and hcrcby authorize Zo Set Backs Forms/Stee!/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenVl ns u Iatio n Roof Sheathinq ll- lB-zcl J l<-5 t tu'{4rP Shear Wall Framinq lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat Jtllasonry Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif FINAL l1-29- 2l t Jd"s a+? â‚¬{/ Certificate of Occupancy Notes, Remarks, Etc. Rev. 08-07-201 5 ls