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BUILDING- INSPECTOR RECORD a SITE.WORK DATE ID/SIG.COMMENTS OWNIiR II UII,I)T.]R DIiI,CA RATION I hereby affrm under penalty of perjury that I anr exempt from the Clontractors' License l.aw for the followinS reason (Sec.7031.5 Business and Profcssion Codc): Any City or County which requires a permit to construct, alter. irnprove, dcmolish or repair any structure. prior to its issuancc. also requires the applicant for such permit to file a sigrrd statemenl that hc or shc is licenscd pursuant to tfre provisions of the Contractor's l,icensed Iaw (Chapter 9, Commencing with .Section 7fiX) ol' Division 3 of the Busines.s and Prof'essions Code) or thal he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Seclion 7031.5 by any applicant for a pennit subjects thc applicant lo a civil pcnalty of not more than five hundred dollars ($5tXl1. _I. as owner of thc property. or my employees with wagcs as thcir solc compcnsation, will do the work and thc structure ls rnt interxletl or offered for salc (Sec.7(X4. Business and Professions Code: Thc Contractor's Licensc l-aw does not apply to an owner of the pmperty who builds or inproves thermru and wlro does such work himself or lrerself or through his or her own employees. provided that such improvements are not intended or oll'ered for sale. Il, howevcr, thc building or improvenrcnt is snld within one year of completion, the Owncr Buildcr will havc the burden of proving that he or she did not build or improvc thc propary for thc purpose of sale). _1, as owner of the property, anr exclusively contracting with licensed conlraclors to construcl tlw project (Sec. 7044, Business arrd hofbssionCode: TheColrtractor'sLicenseLawdoesnotapplytoanowncrofpropertywhobuildsorintproveslhereott. and who contracts for such pro.jccts with a Contractor(s) licenscd pursuant to thc Contractor's Lir:cnsc Law). -IamexemptunderSection-,B.&P.C.forlhisreason.I 1.. r... W()RKI.IRS' CONI PFINSA'I lON DECLARATION I hcrcby aflirm undcr pcnalty of pcrjury onc of thc ttrllowing dcclaration.s: _l have and will nrainlain a Certificate of Consent to Self-lnsure for workers' compensation, as prcvided for by Section 3700 of the [:hor Code, for the performance of the work for which the permit is issued. _I have and will maintain workers' conrpcnsation insurance, as required by Section 3700 of thc labor Code, for lhe performance of the work tbr which this Jrcrmit is issurxl. My workers' compensation insurancc caricr and Jnlicy numbcr arc: Policy Nurnber: lixpires: _l certily that in thc pcrfornrancc of the work for which this permit is issued, I shall not cmploy any pcrson in any manner so as to bccomc subjcct to thc workcrs' conrpcnsation laws of California, and agree that if I should bccomc subjcct to thc workers' compensation provisions of Section 3700 of the Labor C'ode, I shall, f<rrthwith c<lnply with tlrose provisions. WARNING: Failurc to sccurc workcrs'compcnsation covcftrgc is unlawful, antl shal! subjccr an entployer to criminal pJlnies anA civil fines up to one hundred thousand dollars ($100,ffin). in addition to the cost o[ compensation, damages as providcd for the Section 3076 of the Lahrr C'<xle, interest and atlorney's fees. Datc: Applicant: LICENSED CONTRACTOR DECLARATION I hereby aflirm undcr Jrcnalty of Jrerjury that I arn licensed under provision of Chapter 9 (cornrnencing with Scctkrn 7ffn) of Division 3 of the Busincss and Professions Codc, and my liccnse is in full force and effect. License Class: Licensc Number: CONSTRT.'CTION I,ENDING AGI.:NCY I hereby aflirm under Jrenalty of perjury that there is a construction lending agency for the performame of the work for which this prmit is issucd (.Sec. 3097, Civ. C.). Lender's Narrre: [-cn<lcr's Atldrcss: APPLICANT DECLARATION I hereby affirm under lrcnalty of pcrjury one of the following tleclarations: Demolition Permits-Asbestos Notification Federal Regulations (Tille 40, Part6) _Required lrtter of Notification _l certify that thc federal regulations rcgarding asbestos rcmoval are not applicable to this projoct. - _l certify that I havc rcad this application arxl statc that thc abovc information i..orr.--hr"grâ‚¬c to comply with all City and County ordinances and State laws relating to authorize rcprcsentalives of this City and County to cnter uPon the ahove rnentioned property tbr Applicant or Agcnt Pernritee nanre ZO Set Backs Forms/Stee!/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/Ve nVl nsu Iatio n Roof Sheathinq Shear Wall Framinq lnsulation/Enerqv Drvwal! Ext./lnt. Lath Brown Coat [Vasonrv Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Fina! Report Flood Zone Certif. /\ FINAL K-75-Z r U^\lrlrl Certificate of Notes, Remarks, Etc. a Rev. 08-07-201 5