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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/VenVl nsu I atio n Roof Sheathing Shear Wall Framing lnsulation/Enerqy Drvwall Ext./lnt. Lath Brown Coat lt/asonry Pool Fence T-Bar Handicap Req Deputy Final Report Enoineer Final Report Flood Zone Certif A. FINAL 11- 1L'7b1 1ul,x) Certificate of Occupancv V \J Notes, Remarks, Etc.\ OWNER BI.ILDER DELCARATION I hcrcby affirrn undcr pcnalty of perjury that I am exenrpt from thc Contractors' Liccnse law for thc following reason (Scc.7031.5 Business and Profcssion Codc): Any City or County which rcquircs a prmit to construct. alter, improve, dcnrolish or rcpair any structurc. prior to its issuance, also requires the applicant for such pcrmit to filc a signcd statcmcnt that hc or she ls liccnscd pursuant to the provisions of thc Contractor's Licenscd Law (Chapter 9. Commencing with Sc"ction 7000 of Division 3 of the Business and Profcssions Codc) or that hc or she is excmpt thcrefrorn and thc basis for thc allcged exemption. Any violation of Section 7031 .5 by any applicant for a pcrmit subjccts the applicant to a civil penalty of not nrorc than fivc hundrcd dollars ($50O1. _1. as owncr of thc propcrty, or nly cnrployccs with wagcs as thcir solc conrJrcnsation. will do thc work and the structurc is not intcrxlcd or ofl'crcd for salc (Scr.7044. Busincss and Profcssions Code: Thc Contraclor's License [:w docs not apply to an owncr of thc propcrty who builds or inrproves thercon and who does such work hirnself or hersclf or through his or her own crnployees. providcd that such imglrovcnrcnts are not intcrxlcd or offercrl for salc. lf. howevcr. thc buikling or inqrrovcnEnt is mld within onc ycar of comphtion, thc Owncr Builder will havc the burdcn of proving that hc or shc did not buiH or improvc thc proJrcrty for thc purposc of salc). _1. as owncr of thc proprty. anr cxclusivcly contracting with liccnscd conlractors to construct thc projc.ct 1Scc. 7G14, Business and Profcssion Codc: Thc Contractor's License Law does not apply to an owner of propcrty who builds or improvcs thereon, and who contracts for such projects with a Contractor(s) liccnsed pursuant to thc Contractor's Liccnsc [,aw). _l am excmpl undcr Sect B. & P.C. for this rcason. Date:_Owner:- WORKER,S' COM PENSATION DF'CLARAT']ON I hcreby affirm under penalty of pcrjury one of tlrc following dcclarations: _l havc and will maintain a Ccrtificate of Consent to Sclf-lnsurc for workcrs' compcnsation, as povided for by Secti<ln 37fi) of thc Labor Code, for thc perfornunce of thc work for which thc permit is issued. _lhavcandwill maintainworkcrs'colnpensationinsurancc.as requircdbySection3T00ofthcLaborCodc.forlhepcrformanceof thc work for which this pcrmit is issucd. My workers' com[rcnsalion insurancc carricr \ Policy _l ccrtity that in thc Jrcrlbrrnarrcc of thc work for which this permit is issucd. I shall not enploy any Jrcrson in any nunner so as to beconrc subict to thc workcrs'comgrcnsation laws of Calilbrnia. and agrcc that if I should bcconrc subict to thc workcrs' compcnsation provisions of Scction 3700 of thc [:tnr Code. I shall. forthwith comply with thosc provisions. WARNING: Failurc to sccurc workers' cotnpcnsation covcragc is unlawful. and shall subject an cmploycr to criminal penalties and civil fincs up to onc hundred thousand dollurs ($100,ffn). in addition to thc cost of compcnsation. danuges as provided t'or thc Section 3076 of the l-abor Code, intcresl and I hcreby affirnr undcr pcnalty of prjury that I anr liccnsed under provision of Chaptcr 9 (comrncncing with Scction of thc Busincss and hofessions Code. and rny license is in full forcc artd cft'ect. .1 l,iccnsc Nurnbcr:ID 7 o Il..r ,.. I hcrcby afftrm urdcr pcmlty of Frjury thil thcrc is a mnstructk n lcnding agcrcy for the JErforrc of the work for which this pcrmit ir issucd (Sc. 3097, Civ. C.). Lcndcr's Namc: l-cnder's Address: A PPLICA NT NT'CLA RA TION I tucby affrm undcr pcnalty of pcrjury one of the following declarations: Dcmolition Pcrrnits-Asbcstos Notification Fedcral Rcgulations (Title 40, Part6) _Rcqu ired Lcttcr of Notification _l ccrtify that thc lbdcralregulations rcgarding asbcstos rcnrovalarc nol applicablc to this projc"ct. arul statc that thc atnve infornration is correct. I agrcrc to comply with all City and County corrslruclion.and hercby authorize reprcsentat\f this City and County to enter upn the abovc nrcntioncd proprty for .{pplicant or Agent Pernriter name purF)scs. holo / O ,- t-l ,-Lc, 2^r Rev. 08-07-201 5 Date: