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BUILDING. INSPECTOR RECORD SITE.WORK DATE !D/SIG COMMENTS OWNER BI,JILDER DELCARATION I hcrcby affirrn under pcnalty of perjury that I am cxenrpt from the Contractors' License law for the following reason (Scc.7031.5 Busincss and Profcssion Code): Any City or County which requires a pcrmit lo conslruct, alter. improve, demolish or rcpair any structure. prior to its issuance, also rcquires thc applicant for such pcrmit to filc a signcd statcmcnt that hc or she ls liccnscd pursuant to thc provisions of thc Contractor's Licenscd law (Chapter 9, Commencing with Sc.ction 7000 of Division 3 of the Busirrcss and Profcssions Codc) or thal hc or shc is cxcmpt thercfrom and thc basis for the allegcd exemplion. Any violation of Scction 7031.5 by any applicant for a pcrmit subjects thc applicant to a civil pcnalty of not morc than fivc hundred dollars (S500). a _1. as owrrcr of thc fnopcrly. or my cmployces with wagcs as their sole compcnsalion, willdo thc work and thc stnrcture is not intcndcd or offcrcd for salc (Scc.7044. Business and Profcssions Codc: The Contractor's Liccnsc law docs not apply to an owncr of lhc propcrty who builds or inrprovcs thcrcon, and who docs such work himself or hcrsclf or through his or hcr own employces, provided that such improvenrcnt.s arc not intcndod or offercd for salc. If, howcrtr. thc building or inprovcnrcnt is sold wilhin onc )aar of conrphtiorr thc Owrrcr Builder will have thc burden of proving that hc or she did not build or improvc thc property for thc purynscof salc). __1, as owner of the property, am exclusivcly contracting with liccnscd contractors to construct thc projc.ct (Scc. 7O14. Bu.sincss and hofession Codc: Thc Contractor's Liccnse Law docs not apply to an owncr of propcrty who builds or improvcs thcreon. and who contracts for such projccts with a Contractor(s) liccnscd pursuant to the Contractor's Liccnsc [,aw). -l am excmpt under Section-. B. & P.C. for this rcason. I ):rlt' ( )rt ltt'r WORKERS' COMPENSATION DECI ARATION I hcrcby affirnr undcr pcnalty of prjury onc of thc following dcrclarations: _lhavcandwill maintainaCertificateofConsenttoSclf-lnsurcforworkers'conrpcnsation.as providcdforbyScction3T0Oofthc 7*; for ttrc performance of thc work for which thc pcrmit is issucd. will maintain workcrs'insurance. as by Section 3700 of thc [:bor Code. for the pcrformance of ls workers'carrier and policy number arc: \I'}olicy ltiryn* so as to bccome in the pcrformance of thc work for which this pcrmit is issucd. I shall not cmploy any pcrson in any manner subject to thc workcrs'compensation laws of California. and agrce that if I should bcconrc subjcct to ttrc workcrs' compcnsation provisions of Scction 3700 of the l-abor Codc, I shall. forthwith comply with those provisions. WARNING: Failure to sccurc workcrs' colqrcnsation covcrage is unlawful. and shall subjcct an employcr to criminal penalties and civil fincs up to onc hundred thousand dollars ($100,0m). in addition to the cost of compcnsation. damages as provided for the Scctiorr of thc intcrcst and attorncy's fccs. DECLAIIATION I hcreby affirm under pnalty of pcrjury that I am licenscd under provision of Chaptcn 9 (comnrncing with Section 7000) of Division 3 of the Busincss and Professions Code, ard my license is in full forcc ard effcct. Liccnse Nulnbcr*- >(> W I hcrcby amrm undcr pcnalty of Frjury that thcrc is a construction knding agcrcy for thc pcrforMcc of lhc work for which this Frmit is issucd (56. 3097, Civ. C.). kndcr's Nam' lrnder's Address: A PPLI CA NT DECLAITAT'ION I hercby affrm undcr pcnalty of perjury one of thc following declarations: Dcmolition Pcrmils-Asbcstos Notificalion Fcderal Rcgulations (Titlc 40. Part6) -Requ ired [-etter of Notification _l ccrtify that thc fcdcralregulations regarding asbcstos rcnrovalare not applicable lo this projcrct. -6"n fyrhat I havc read this appticalion and starc rhat the atxlve infornution is correcl. I agrec lo comply with all City and County ordinanccs and Statc laws relating to building construction. abovc nrcntioned property for inspection purg)scs. '\ upn thc ,\pplicant or Agcnt I'ernrilee nanre ard hereby authorize representatives of this City and >b 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 nlEnerqy Drvwall Ext./lnt. Lath Brown Coat J\Iasonry Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif L FINAL /2-/-70 fLctl A/EUS czrl Certificate of Occupancy Notes, Remarks, Etc. Rev. 08-07-201 5 oare' I