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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER B I.IILDER DELCA RATION I hcreby attirm under pcnalty of perjury that I am exempt from thc Contractors' Liccnsc law for the following reason (Scc.7031.5 Busincss and Profcssion Codc): Any City or County which rcquircs a permit to conslruct, alter. improvc, dcmolish or repair any structurc, prior to its issuance. also rcquircs thc applicant for such pcrmit to filc a signcd statemcnt that hc or shc is liccnscd pursuant to thc povisions of thc Contractor's Licenscd law (Chaplcr 9, Comnrencing with Scrtion 7000 of Division 3 of the Busincss and Profcssions Codc) or that hc or shc is cxcmpt thcrefrom and the basis for the allcged exemption. Any violation of Sectkrn 7031.5 by any applicant frrr a pcrmit subjcrts thc applicant to a civil penalty of not morc than five hundrcd dollars ($500). _1, as owner of the propcrty, or my employccs with wages as thcir sole compcnsalion. will do the work urd the structwc is mlt intcndcd or offered for sale (Scc.7044, Busincss and Professions Codc: The Contractor's License law docs not apply to an owncr of the propcrty who builds or impmvcs thcreon urd who does such work hirnself or hcrsclf or through his or hcr own employces. provided that such improvcnrcnts are nclt iruenclcd oroffered for salc. If. howcrrr. thc buiHing or inprovcnrent is sold within one )rcuu of cornphtion, thc Owrrcr Builder will have the burdcn of proving that hc or she dirJ not buiH or improve the proprty for tlr purynsc of sab). _1, as owncr of the propcrty. am exclusively contracting with liccnscd contractors lo construct thc pro!:ct (Scc. 7M4. Busincss and Prrofcssion Codc: Thc Contractor's Licensc Law docs not apply to an owncr of propcrty who builds or improves thercon. and who contracts for such projccts with a Cnntracto(s) liccnscd pursuant to the Conlraclor's Liccnsc kw). -l am exenlpt under Scction- . B. & P.C. for this reason. Date:_Owner: WOnfBnS' CtlfttPfns DECLAITATION I hcreby affinn undcr pcnalty of pcrjury one of thc following dcrlarations: _l havc and will maintain a Cenificate of Conscnt to Self-lnsure lbr workers'con{rcnsation. as ;novidcd for bySection 3T00 of thc Labor Codc, for the pcrfornurnce of the work f<rr which the pcrmit is issucd. Ne,t ,tr" havc and will maintain workcrs' compcnsation insurance. as rcr;uired by Seclion 37fi) of the l.abor Code. for thc ;rcrformarrce of work frrr u,hich this pcrnrit is issued.Mv workcrs' comncnsationLvuLh insurance canicr and plicy numbcr arc: \ lz,o Policy \I $Q-f "crrify rfur in thc 1rcrformrcc of the work for whhh this prmit is issued. I shall nor cnploy any Jrcrson in any rmrcr s as Io bccom subjst to thc wtrkss' @mlEnslion laws of Cdifomia, ild agE thd if I should bccom subjct Io Ilrc workcro comlrcnsation pmvisions ofSction 3700 ofthc Labor Codc. I slEll, fonhwith omply with thos prcvisions. WARNING: Failurc to scurc workcrC con{rcnstion covcmgc is unlawful, alxl shall subtrt an cmplolrcr to qiminal lEullbs lnd civil fincs up lo onc hunclred lhousand dollars ($l in adcliti<ln to thc copg[-sqfrcnsation. darnages as provided for the \*labor Code. \zc intcrcst and I hcrcby alllrnr undcr Jrcnalty ol'pcrjury that I ant liccnscd undcr provision 9 (conrnrncing with Scction 7000) of Division 3 of thc Busincss and Prol'cssions Code, and rrry liccnsc is in full lilrcc arxl cffcct. Licensc \(,Number:1 SU, L \\zr CtY W I hcrcby affm urder Fnally of pcrjury thal thcrc is a @n$ruction hnding agcrcy for thc lrfot1llmc of thc work for which this pemit is issued (Sa. 3097, Civ. C.). lrndcr's Name: lrndcr's Addrcss: APPLICANT DFCLARATION I hcrctry aflinn undcr pcnalty of Jrcrjury onc of thc following dcclarations: Dcrnolition Pcrmils-Asbcstos Notification Fcdcral Regulations (Titlc 40, Part6) -Rcqu ircd lrttcr of Notification _l ccrtify that thc fedcralrcgulalions rcgarding asbcstos rcnnvalarc not applicablc to this proi'ct. _l ccrrily that I havc read this and statc that the abovc inforrnation is corrcct. I agree to conrply with all City and County ordinances and State [-aws upon thc Loabove rncntioncd properly ftrr Applicant or Agent I'ernritee nilnre cunstruction. and rcprcscntatives of Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bf loor/VenUl nsu I atio n Roof Sheathing Shear Wall Framinq lnsulatio nlEnerqy Drvwall Ext./lnt. Lath Brown Coat Jvlasonry Pool Fence T-Bar Handicap Req. Deputv Final Report Engineer Final Report Flood Zone Certif. /,\ FINAL /Z /z-z/'z 02â‚¬) dk !'7,U Certificate of Occupancv I, Notes, Remarks, Etc. Rev. 08-07 -201 5 \0