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BUILDING- INSPECTOR RECORD SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION . I trcrcby alfirm under pcnalty of pcrjury that I amexcmpt from thc Contraclors' Liccnse law for thc following reason (Sec.7031.5 Busincss and Prof'cssion Codc): Any City or County which rcquircs a pcrmit to construct, alter, irnprovc. dcmolish or rc;xrir any structurc. prior to its issuancc. also rcquircs thc applicant for such pcrmit to filc a signcd statcmcnt that he or shc ls liccnscd pursuant to thc provisions of tlre Contractor's Liccnsed l-aw (Chapter 9, Commencing with Section 7000 of Division 3 of the Business and Profcssions Code) or that he or shc is cxcmpt thcrcfrom and the basis for the allcged cxemption. Any violation of Scction 7031 .5 by any applicant for a permit subjcrcts thc applicant to a civil pcnalty of not more than five hundred dollars ($500). _1. as owncr of the will do thc work and thc structue is not License [:w dtlcs not apply to an owner of the pnrpcrty who builds or improves thcrcnn. and who does such work hirnsclf or hcrsclf or through his or her own crnployccs. providcd that such improvenrcnls arc not intendod or offcrcd for sale. lf. howcrar. thc buiHing or inryrrovcnrent is mld within one yqrr of conrphtio[ thc Owncr Buildcr willhavc thc burdcn of proving thal hc or shc did not buib or inqlrove thc propcrty for ttrc purposcof salc). _1, as owncr of thc pn)pcrty. am cxclusivcly contracting with liccnscd conlractors to construct the pro.icrt (Scc. 7W, Busincss and Prnfession Code: Thc Contractor's Liccnse Law docs not apply to an owncr of propcrty who builds or improves thercon, and who contracls for such projects with a C-ontractor(s) licenscd pursuant to thc Contractor's License kw). -l anr cxcrnpt undcr Scction-, B. & P.C. for this rcason. Date: IVOIIKIiILS' C( TIII PENSATION DI'CLARATION I hcrcby affirm undcr pcnalty of prjury onc of thc following doclaralions: _l havc and will maintain a Cerrificatc of Conscnt lo Sclf-lnsurc for workcrs'compensation. as provided for bySection 3700 of thc L:bor C-ode. for thc perfornrancc of thc work for which thc perrnit is issued. _l havc and will maintain workers' compcnsation insurarrcc. as rcquircd by Section 3700 of the [:bor Code, for the performancc of the work fttr which this prmit is issucd. My workcrs' comgrcnsation insurance carricr and plicy numbcr are: Carricr: Policy Numbcr: Expires: _l ccrtify that in the pcrformance of thc work for which this pcrmit is issucd. I shall not crnploy any pcrson in any rnnncr so as to bccomc subjccl to thc workcrs'compensation laws of California, and agree that if I should bcconr subject to thc workers' compcnsation provisions of Section 3700 of the hbor Code. I shall, forthwith comply with thosc provisions. WARNING: Failurc to sccurc workers' conpnliation covcragc is unlawful. and shall subict an employer to criminal penaltics and civil fincs up to onc hundrcd thousand dollars ($100,0m), in addition to the cost of comlrcnsation, danragcs as providcd for the Section 3076 of the latnr Codc, intercst and attorney's fccs. Applicant: LICENSED CONTRACTOR DF'CI-ARATION I hcrcby affirrn undcr pcnalty of perjury that I am liccnscd under provision of Chaptcr 9 (comnnrcing with Section 7000) of Division 3 of thc Busincss and hofes.sions Code. and my liccnse is in full force atd cffcct. Liccnse Class: Licensc Numbcr: W I hcrcby .ffirm undcr JEnalty of ]rcrjury that thcrc is a consructk n lcnding agcrEy for thc performcc of lhe work for which this lsmil is issucd (Se. 3097, Civ. C.). lrndcr's Nanrc: l*tds's Addrcss: AIELICAITLDECI.A8AtrON I Hy aFm under pcnalty of pcrjury orc of thc folbwing dElsntions: Demlition Pcrmits-Asbestos Notification Fedâ‚¬ral ReSulations (Title 40, Psn6) _Required lrtlcr of Ndiliclrbn -l c.rlify that the fcdcnl rcgul8tions rcgardinS asbcslos rcmval rc ml applicable to this pDlxt. _lrenify thrt I have rcad this application and statc thst the sbove infortrEtion is corecl. I agrc to cor{,ly with 8ll Cily and County ordinires qrd Statc trws rctaring to building comtnrctiotr atd hercby authorire rcDre$ntatiws of lhis City utd Couty to cnt6 upon 0E sborc mntbrcd prcpcny ftr inspcction pupos. Applml or Ag6t Slgnalure: Drlc:- PcmlaE namc (Drinl): Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bf loo r/VenUI ns u latio n ^l I ,"/ Roof Sheathino il','1.0 Uru1ry6 ?y0 Shear Wall Framino Insulatio nlEnergy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req. Deputv Final Reoort Engineer Final Report Flood Zone Certif I I ^/.a FINAL Eil?f)UUltu n{0 Certificate of Occupancy I Notes, Remarks, Etc. Rev. 08-07 -201 5 Date:_ Date:_ Contractor:-