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SITE-WORK DATE ID/SIG.COMMENTS OWNER BUII,DER DELCARA'I'ION
<br />I hereby aflirm under penalty of perjury that I am exempt fmm the Contractors' License Law for the following reason (Sec.70.l1.5
<br />Business antl Profession Code): Any City or County which requires a permit to construct. alter, imprrrve, dermlish or repair any
<br />structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant
<br />to tlrc prrrvisions of the Contractor's Licensed [-aw (Chapter 9, Commencing with Section 7(XX) of Division 3 of the Business and
<br />ProfessionsCode)orthatheorsheisexempttherefromandthebasisfrrrtheallegedexemption. AnyviolationofSectionT0Sl.5byany
<br />gplicant for a permit subjects the applicant to a civilpenalty of not nxrre than five hundred dollars ($5m).
<br />{[!r,Kr;.., of the pn)perty, or my empkryees wirh wages as their vrh compensation, wiltdo the w.rk and the structurc is not
<br />intendetl or offerecl frrr sale (Sec.7044, Business and hofessions Code: The Conlraclor's License Law does not apply to an owner of
<br />the property wlxl htrilds or improves thereon, and whr drrcs such work himself or herself or through his or her own empkryees.
<br />provided that such improvenrnts are not intended or offere<l for sah. If. however. the huilding or improvenrnt is sokl within one )rir
<br />of completion. the Owner Buikler will have the burtlen of pnlving that he or she did not huild or impnrve tlre pnlperty firr the purJxrse of
<br />sale).
<br />-1.
<br />as owner of the pr()perty. am exclusively contracting with licensed conlractors to construct the project (.Sec. 7044. Business
<br />and ProfessirnCode:TheContractor'sLicenseLawdoesnotapplytoanownerofpropertywhohuildsorimprovesthereon,
<br />and who contracts for such pnrjects with a Contracto(s) licensed pursuant to the Contractor's l-icense Law).
<br />t
<br />-l
<br />am exempt,;rncler Section-, B. 4lP.C. for this ,Gun. , //l I t
<br />(.,*.,- /, " /wOlftERs'collIPFAISATIoN lt \-/
<br />DECLARATION
<br />I hereby affirm under penalty of perjury one of the following declarations:
<br />_l haveandwill maintainaCertifrcateofConsenttoSelf-lnsurefrrrworkers'comlrcnsation.as pnrvidedforhySection3T(X)ofthe
<br />Lrbor Code. forthe performance of the work frrr which the perrnit is issued.
<br />_lhaveandwill maintainworkers'compensationinsurance,as requiredbySection3T(X)ofthel,ahorCode,fortheJrcrformanceof
<br />the wrlrk for which this permit is issued. My workers' compensation insurance carrier and Jmlicy numher are:
<br />?
<br />7 that in the perfirrmance of tlre work frrr which this pernrit is issuetl. I shall not elnpkry any person in any manner
<br />so as to heconr sub.iect to the workers' compensat ion laws of Califrrrnia. and agree that if I shrultl hecome subject to the
<br />workers' compensation provisions of Section .37(X) of the l;rhrr Cqle, I shall. forthwith comply with those provisions.
<br />WARNING: Failure to secure workers' compensation coverage is unlawful. and shall sub.ject an ernpkryer lo criminal penalties antl
<br />civil fines up to one hundred thousantl dollars ($l(X),Un), in addition to the cost of compensation, damages as provided for the'ij^7Yr'ryi'r"**H;,"Wcy lt', ,4 ,-' c //n.JA
<br />LICEiTSLD COIqgAt"l'OR ,_l
<br />Iherehyaffirmunderpenattyofperjurythattamticensed,ffiChapter9(ctlmmencingwith'Sectitrn7(Xx))ofDivision.3
<br />of the Business and ftofessions Code. and my license is in full force and effect.
<br />[.icense (Number:
<br />Date: _ Contractor:
<br />CONS'TRUCTION LE,NDING AGENCY
<br />I hereby affirm under Jrnalty of Jrrjury that there is a construction lending agency for the perfonnance of the work firr which this Jrrmit is
<br />issued (Sec. .1097, Civ. C.).
<br />I-ender's Name:
<br />o
<br />l-ender's Adtlress:
<br />APPI ICAN'I' DECLAIL{TION
<br />i:sililH:i::rfi[:lrffi;H;ji],H,,,::.l;:H":1 ,*u, '
<br />_Required Letter of Notifrcatkrn
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<br />certify that the federal regulations regarding astrcstos rerxrval are not applicable to this project,
<br />*rr^Gthat I have reatl this apptication arxJ state that the ahrve informathn is correct. I agrec to comply with all City antl Counry
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<br />permiteename ,r*r,,P-(A lY^W tf1/ U U7/<'tJ
<br />Set Backs
<br />Forms/Steel/Holdowns bA nOsL 4*W
<br />Erection Pads t- t
<br />UFER Ground
<br />SLAB Floor I
<br />S u bf loor/Vent/l ns u I ation ia 1b Dflft{I y *t, I Tlrlp Dk*n
<br />Roof Sheathing a Dft'+Lc -*r2l
<br />Shear Wall -1 It 1r)DRnl6st .##9_
<br />Framing 1 q 7/)r*\inr L-trffi
<br />lnsu lation/Energy llZz-,'l^o f k,..V\-.il->q
<br />Drywall 1r 7A(bh ort- /"W
<br />Dlnt. Lath I Vno-#V
<br />rown coat (r /?rl D f*fl 7l2slz-z D/fr)6?-tP&
<br />Masonry II JU
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report t
<br />Flood Zone Certif
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<br />FINAL L I w hH-n "l
<br />Certificate of Occupancv
<br />Notes,,Remarks, Etc I
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<br />BUILDING- INSPECTOR RECORD
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