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BUILDING- INSPECTOR RECORD ID/SIG.COMMENTSSITE.WORK DATE Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bf Ioor/Ve nVI n s u Iatio n Roof Sheathinq Shear Wall t/rFraminqt ;7 -70 lnsulation/Enerov IDrvwallI -lL -rh W 4ll t Ext./lnt. Lath Brown Coat Jt/asonry n Pool Fence I T-Bar II{'t Handicap Req. Deputv Final Report \-/ Enoineer Final Report Flood Zone Certif. I FINAL Certificate of I Notes, Remarks, Etc.\-/ (i-9-7-. Utu||lS, 4 )la Ut Ax )rl^tE f)'\Iv\J otvNI.:R I)EI,(IARA'I'ION I hereby affirm under penalty of perjury that I am exempt fronr the Contraclons' License Law for the following reason (Sec.7031.5 llusincss and Profession Code): Any City or County which requires a pcrrnit to conslrucl, alter. irnprove, demolish or repair any struclure, prior to its issuanc'e. also requires the applicant tbr such lrcrnrit to file a signed statement that he or she is licensed pursuant to thc prrrvisions of the Conlraclor's Licensed l-aw (Chapter 9. Comrncncing with Scction 7fi)0 of Division 3 of the Business and Prot'essions Code) or that he or she ls exempt therefronr and the basis tbr the alleged exemption. Any violation of Section 703 I .5 by any applicant for a perrnit subjects thc applicant to a civil penalty of not rnore than five hundrcd dollars ($5tXt). _1. as owner ol'the pro1rcrty, or my ernphyees with wages as thcir solc compcnsation, will do the work and thc structure ls rnt interxletl or offeretl for salc (Sec'.7O14, Business and Pmfcssions Codc: The Contractor's License l-aw docs not trpply to an owner of the property who builds or improves thereoru arxl who docs such work hinrself or herself or through his or her own employees, provided that such improvenrents are not intended or olTcrcd for salc. Il, howevcr. thc building or improverncnt is sold within one )aar of conrpletion, tlrc Owner Builder will have the burden of proving that lrc or she did rnrt build or improve ttrc property for tlrc purposc of sale). _1, as owner of the propcrty, am cxclusively contracting with liccnsed conlraclors lo conslrucl the project (Sec. 7044, Business and Pnrfesskxr Code: The Contractor's Licerrse Law does not apply to an owner of property who builds or improves thereort. and who contracts lor such projects with a Contractor(s) liccnsed pursuant to the Contractor's Licensc taw). _l am exempt under B. & P.C. lbr this reason. l)ate: Owner: WORKIqRS' COM IDI.INSATION DECLARATION I hcreby atlirm undcr penalty of perjury one of the following dcclaration.s: -l have and will nraintain a Certifrcate of Consent to Selt'-lnsure for workers' compensation, as provided for by Section 3700 of the , Latxrr Code, for thc Jrcrforrnarrcc of thc work lirr which thc permit is issucd. \r/. arxt wilt maintain workers' contpensation insurance, as required hy Section 163\t111rk ftrr which this Jrcrnrit is issucd. My workcrs' compcnsation insuruncc carric'r 3700 of the labor Code, for the perfornunce of plicy numhcr arc: Policy ) _l ccrtity that in thc pcrfornrancc of the work ftrr which this Jrcrnrit is issucd, I shall not cmploy any frcrson in any manncr so as to bccorne suhjcct to the workers'compcnsalion laws of California. and agree that if I should bccomc subjcct to the workcrs' comlrcnsation provisions of Section 3700 of the Labor Code, I slurll, forthwith comply with thosc provisions. WARNING: Failure to securc workcrs'comlrcnsation covcrage is unlawful. antl shall subjcct an employer to criminal penaltics and civil fines up to one hundred thousand dollars ($l ion to lhe cost compensation, damages as provided for the Section 3076 of tlrc Latxrr Code. interest and fees. I hcrchy al'l'irrn undcr pcnalty of pcrjury that I arn licenscd 9 (commencing with Section 7(Kn) of Division 3 of the Business and Professions Code, and my license is in full force and effect. -/t oLicensc I hercby atlirm under penalty of perjury tlut there issuctl (.Scc. 3097, Civ. C.). Lendcr's Namc: agency for the grcrformance of the work for which this pcrmit is lrndcr's Address: APPLICANT DECLARATION I hereby affurn under penalty of perjury one of the following declarations: Demolition Permits-Asbstos Notification Federal Regulations (Title 40, Part6) -Rcquired lrtter of Notification certity that the federal rcgulations regarding asbestos removal are not applicable to this project. I have rcad this application arxl state that lhc above infornration is correct. I agree to comply with all City and County ordfumnces and State Laws relating to conslruction, anl herehy City and County to enter ugln the atxlvc mcntioned proprrty lirr Applicant or Agcnt Permitec nanre \< authorva rep:sentatives of this 5 zb 7 -2015 lv \ a