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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcrcby affirrn undcr pcnalty of pcrjury that I am cxcnrpt from rhe Contractors' Licensc law for the following rcasofi (Scc.7031.3 Busincss arxl Prof'cssion Code): Any City or County which rcquircs a pcrmit to construct. altcr, improvc. dcmolish or reprir any structurc. prior to its issuance, also rcquircs thc applicant for such pcrmit to filc a signcd statcmcnt lhat hc or shc is liccnscd pursuant to thc pl'ovisions of thc Contractor's Licenscd Law (Chaptcr 9. Commcncing with Section 7000 of Division 3 of thc Busincss and Profcssions Codc) or that hc or shc is cxcmpt thercfronr and thc basis for thc allcgcd cxcmption. Any violation of Section 703 L5 by any applicant for a ;rcrmit subjccts thc applicant to a civil penalty of not morc than five hundrcd dollars ($500). _1. as owncr of thc Foperty, or my employccs with wagcs as thcir solc compcnsation. will do the work and thc stnrcture is mt intcrxlcd or offcrcd for salc (Sec.7M4. Busincss and Pnlfcssions Codc: The Contractor's Licensc law docs not apply to an owncr of thc proprty who builds or improvcs thcrctrn. and who does such work himself or hersclf or through his or her own cmployecs, provided that such improvcnrcnts arc not intcndcd or oflbrcd for sale. lf, howcvcr. the building or inqrrovcnrcnt is sold within onc ycar of cornphtioru thc Owncr Buildcr will havc thc burdcn of proving thal hc or shc did not buikl or improvc thc proprty for ttrc purgrsc of salc). -i. as owner of thc proprty. am cxclusivcly contracting with licenscd conlractors lo construct thc project (Sec. 7044, Busiltcss and Profq;sion Code: Thc Contractor's Liccnse Law docs n<lt apply to an owner of propcrty who huilds or improvcs lhcrcon. and whc contracls for such pojccts with a Glnlractor(s) liccnscd pursuant to the Contraclor's Licensc Law). _l am cxempt undcr l]lhis rcason. DF'CLARATION I hercby alfirrn undcr penalty of pcrjury onc of thc following dcclarations: _lhavcarxlwill nuintainaCertificatcofConscnttoSclf-lnsurcforw<lrkcrs'compcnsation.as providedforbySection3T00ofthc I-.abor (bdc. for lhc pcrfornuncc of thc work for which the pcrmit ls issucd. _l havc and will rnaintain workcrs' comlrcnsation insurance, as rcquircd by Section 3700 of lhe Labor Code, for the pcrformance of thc work for which this pcrmit is issucd. My workcrs' compcnsation insurancc carricr and policy number arc: Policy Numbcr: Expires: _l ccrtify that in the pcrformarrce of the work for which this pcrmit is issued, I shall not cmploy any person in any nurnncr so as to bccomc subjcct to thc workers' cornFrcnsation laws of California. and agrcc that if I should bcconrc subjcct to tlrc e workers' corrqrcnsation provisions of Scction 3700 of the l-abor Code, I shall. forthwith comply with those provisions. WARNING: Fhilurc to securc workers' conrpcnsation coveragc is unlawful. and shall subject an cmployer to criminal Jrcnalties and civil fincs up to onc hundrcd thousand dollars ($100,000), in cost of compcnsation, damagcs as providcd for thc Section 3076 of thc kbor Crxle. intcrcst arxl Orr" I hcrcby affirrn undcr pcnalty of pcrjury that I arn liccnscd Chaptcr 9 (commencing with Section 7000) of Division 3 of the Busincss and Profcssions Co<le. and my licensc is in full forcc and effect. Lrcense Class: Liccnsc Nurnber: Date:_ W I hcrcby allimr undcr Jrcmlty of pcrjury thal thcrc is a @nstruction lcnding agercy for thc trrfolffie of thc work for which thls lEmit is issucd (Ss. 3097. Civ. C.). [.cnder's Narne: [-cndcr's Addrcss: APPI ICANT DECLARATION I lucby affrrm undcr penalty of pcrjury one of thc following declarations: Dcmolition Permits-Asbcstos Notification Fedcral Regulations (Title 40. Part6) -Rcquircd l.cttcr of Notification _l ccrtity that lhe tbdcralrcgulations rcgarding asbcstos rcnxrvalarc nol applicable to this prrtject. ' I certify that I havc rcad this application and state that ordinanccs and State [-aws rclating to building etxrvc rrrntioncd property lbr Applicant or Agent l'ernrilee nnnle thc Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenUl ns u latio n I Roof Sheathinq lr/z{zs Dfr+tr, Shear Wall ( Framinq lnsulatio nlEnergy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req. Deputy Final Report Enqineer Final Report Flood Zone Certif I FINAL lzl llU D*#C, Certificate of Occupancy Notes, Remarks. Etc rl ,- I J Rev. 08-07 -201 5 I o*u,J/- /o - Z? o,tu, //-/2- 7C+