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BUILDING- INSPECTOR RECORD SITE-WORK DATE ID/S!G.COMMENTS Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loo r/VenVl nsu latio n Roof Sheathinq Shear Wall Framinq lnsulatio nlEnergy Drywall Ext./lnt. Lath Brown Coat lt/asonry Pool Fence T-Bar Handicap Req. Deputy Final Report Enqineer Fina! Report Flood Zone Certif ,/ll ,t \ FINAL /Z /q /22, a)rS(h,t I Cefiificate of Notes, Remarks, Etc , l/^I A l/h OWNER BTIILDER DELCARATION I hcrchy aflrnr undcr pcnalty of prjury that I am exempt from the Contractors' Licensc law tbr thc following reason r$ec.7031.5 Business and Profcssion Code): Any City or County which requires a pcrmit to construct, alter, improve. dcmolish or repair any structurc, prior to its issuancc, also rcquircs thc applicant for such Jrrmit to file a signcd staterrcnt that he or she is licenscd pursuant to the provisions of thc Contractor's Licenscd Law (Chaptcr 9. Commencing with Scrtion 7000 of Division 3 of thc Busincss and Pmfessions Code) or that he or she is cxcmpt thcrefrom and thc basls for thc allcgcd cxemption. Any violation of Section 7031.5 by any applicant for a pcrmit subjcrts the applicant to a civil pcnalty of not more than fivc hundred dollars ($500). _1. as owner of thc propcrty, or my employces with wages as their solc compcnsation. willdo thc work and the stnrcturc is not intcndcd or offcred for sale (Scc.7044, Business and Profcssions Codc: Thc Contractor's License law does not apply lo an owner of the propcrty who builds or improves thcrcon. and who docs such work hirnself or hcrsclf or through his or her own employecs. providcd that such inrprovenrcnts arc not intcrxled oroffercrJ frrr salc. lf, howewr. thc buiUing or inprovcnrcnt is sold within onc )tar of complction. thc Owrcr Buildcr will havc thc burden of proving that trc or shc dkl not build or improvc the proprty for th purynsc of salc). _1. as owncr of the property. am cxclusivcly contracting with liccnscd contractors to construct thc project (Sec. 7M4. Busincss altd hfcssion Codc: Thc Contractor's Licensc Law docs n<lt apply to an owncr of propcrty who builds or improvcs thercon. and who contracts for such projects with a Contractor(s) liccnscd pursuanl to thc Contractor's Liccnsc l-aw). -l arn excmpt undcr Sc.ction-. B. & P.C. for this reason. I )irlr. ( )rt ttcr: WORKERS' COMPENSATION DECI ARATION I r",krcby affirrn under pcnalty of pcrjury one of thc following dcclarations: _l havc and will maintain a Certificate of Consent to Sclf-lnsurc for workcrs'compensation. as provided for by Scction 3700 of the labor (bde. for the pcrformance of thc work for which the permit ls issued. 9fnor" and will maintain workers' compensation insurance. as rcquired by Scction 3700 of rhc l,abor Code, for the pcrformance of 'thcr work for which thi.s pcrmit is issued. My workers' compcnsation insurancc carricr and gmlicy numbcr are: (- Policy -_l ccrrify that in thc prlbrmance of thc work for which this pcrmit is issucd, I shall not employ any pcrson in any nunnet so as to bccome subjcct to thc workcrs' compcnsation laws of California. and agrce that if I should bccorp subject to thc workcrs' compensation provisions of .Scction 3700 of thc [:tnr Codc. I shall. forthwith comply with thosc provisions. WARNING: Failurc to sccurc workers' compcnsation covcragc is unlawful. and shall subpct an to criminal pcnaltics and civil fincs to onc hundrcd thousand dollars ($100.0001. in addition to the cost of danngcs as provided Scction of thc [-atnr Code. intcrcst ard I hcrcby affirm undcr pcnalty of perjury that I arn licenscd Chaptcr 9 with Section 7000) of Division 3 of thc Business and Profcssions Codc, and nry license is in full forcc and cffcrct. c(o CL Liccnsc Conlractor: CONSTRUCTION LENDING AG ENCY I hcrcby allrm undcr pcnalty of prjury thal thcrc is a conslruction lending agcncy for thc performancc issucd (Scc. 3097. Civ. C.). work for which this pcrnrit is Lrndcr's Name: lrnder's Addrcss: APPLICANT DBCI ARATION I lrrcby alf'rrnr undcr penalty of pcrjury onc of thc lbllowing dcclarations: Dcnrolition Pcrrnits-Asbcstos Notification Fcdcral Rcgulalions (Titlc 40. Part6) Lct tcr ol' Not ilication thc fcdcralrcgulatiorrs rcgarding asbcstos rcnmvalarc not applicablc to this projccl. ccrtify that I havc rcad this application and state that thc with all City and County arxl Statc l-aws rclating to building construction, above mcntioned propcrty for Apllliurnt or Agenl I)erlnilee name atnvc information is corrcct. I of this City and to Rev. 08-07-201 5 I I)nlt: