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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/Ve nVl nsu latio n Roof Sheathinq Lta-2D fXZ*e lol Shear Wall Framing Insulation/Energy Drywall Ext./lnt. Lath Brown Coat Jt/asonry Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif FINAL l r-/ .z.c)l- CB lefta> *2n Certificate of Occupancv Notes, Remarks, Etc. \ / I I hereby affirnr under penalty of perjury that I am exempt fronr the Cbntraclors' License law for the following reason (Scc.7031.5 Busincss and Prolbssion Code): Any City or County which requircs a pcrmit to construct, altcr, irnprove, dernolish or repair any structure. prior to its issuance. also requires the applicant tbr such Jrrntit to file a signed slaternent that lr or she is licensed pursuanl to thc provisions oI thc Conlractor's l,icensed law (Chaptcr 9. Commcncing with .Scction 70fi) of Division 3 of the Business and Prot'essions Cotle) or that he or she is exempl therefiom and the basis tbr tlrc alleged exemption. Any violation of Section 7031 .5 by any applicant for a lrrmit subjects the applicant to n civil penalty of not more than five hundred dollars ($5tXl1. _1. as owner ol'thc property. or my employees with wages as thcir snlc compcnsation, willdo the work and the stnrclure is not intended or offered for sale (Sec.7(X4, Business and Professions Code: Thc Contractor's Licenrc Law does not apply lo an owner of the property wlxr builds or improves therurn, arxl who does such work himself or hrself or through his or her own employees, provided that such irnprovemnts are not intended or ollered for salc. Il. howcvcr, thc building or funpnrverrcnt is sold within onc year of conplctiorl thc Owncr Builder will have the burden of proving ttrat lre or she did not buikl or impnovc ttrc propcrty for thc purp;sc of sale). -1. as owner of the property, am exclusively contracting with liccn.sed conlractors to construct the pnoject (Sec. 7044, Business and holbssbn Code: The Contraclor's License Law does not apply to an owner of proprty who builds or improves thereon. and who contracts lor such projects wilh a Contractor(s) licensed pursuant to the Contractor's License l-aw). -IanrexemptunderSection-'B.&P.C.forthisreason.Date: Owner: WORKI,IRS' COM PI,INSATION DECLARATION I hcreby aUirm under penalty of pcrjury onc of thc following dcclarations: _l have and will mainlain a Certilicate of Consent to Self-lnsure for workers' compensation, as provided for hy Section 3700 of the Lahor Code, for the pcrformance of the work lbr which the Jrermil is issued. f,rrurrand will maintain workers' conrpensation insurance, as required by Section 3700 of the labor Code, for lhe Jrerfornunce of ( the work fbr which thi.s permit is issued. My workers' comlrcnsation insurance carrier antl plicy number arc: _1,L^ l- .C . .a -a _l ccrtity that in thc prfornurncc of thc work for which this pernrit is issucd, I shall not employ any frcrson in any manner so aslobccorncsuhjccttothcworkcrs'conrperrsationlawsofCalifornia,andagrccthatiflshouldbccomcsubjccttothc workers' comJrcnsation provisions of Section 37fi) of the Labor Codc, I shall, f<rrthwith c'onrply with thosc provisions. WARNING: Failurc to secure workers'c<lmpcnsation covcr.lge ls unlawful, and shall subjcct an cmploycr to criminal Jrenalties and civil fines up to one hundrcd thousand dollars ($l(X).(Xru). in addition to the cost of conrlrcn.sation, damages as provided for the Section hcrcby of thc Busincss and Professions Co<Ie, ard my liccnsc is in full tbrce arxl ctfcct. L-z'\Nurnhcr:3-5'L CONSTRI.'CTION I,ENDING AGENCY I hercby aflirm under penalty of perjury that there is a construction lending agercy tbr the performancc of the work for which this pcrmit is issucd (Scc. 3097, Civ. C.). [-cnder's Name: [.cnder's Address: APPLICANT DECLARATION I lrrcby affrm under penalty of perjury one of the following declarations: Denrolition Permils-Asbestos Notification Federal Regulations (Title 40, Part6) -Required l.ctter of Notifrcation -l certity that the federal regulations regading ashstos renroval arc nol applicable to this pro.ject. certify that I havc rcad this applicalion arxl state that the above information is correct. I agrcc to oomply with all City and County ordinances antl State Laws relating lo huilding constrctiorl and herehy autlxrrize representalives of thi.s City and County lo enter ug>n the atxrvc mcntioncd propcrty L or Agcnt nalue 0B-07-201 5 t I 1). ?l /\,--,,,r",3-t-b