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BUILDING. INSPECTOR RECORD SITE-WORK DATE !D/SIG,COMMENTS OWNER BUILDER DELCARATION ' . I hcreby affirm undcr Jrcnalty of perjury that I am exempt from the Contractors' Licensc [:w for the followrng reason (Sec.7031.5 Busincss and Profcssion Codc): Any City or County which requircs a pcrmit lo construct. altcr. improve. dcmolish or rcJrair any structurc, prior to its issuancc, also rcquires the applicant for such pcrmit to fih a signcd stalemcnt that he or she ls licenscd pursuant to lhe provisions of thc Contractor's Licensed [:w (Chapler 9, Commencing with Section 7000 of Division 3 of the Busirress and Professions Codc) or that hc or she is exempt thcrefrom and the basis for thc allcgcd excmption. Any violation of Section 7031.5 by any applicant for a 1rcrmit subjccts thc applicant to a civil penalty of not morc than five hundred dollars ($500;. _1. as owncr of thc F,roF,crty. or my employecs with wagcs as their solc compensation. will do the work and the stnrcttne is rnt intcndcd or offcrcd for salc (Sc.c.7044. Busincss and Professions Codc: The Contraclor's License [-aw does not apply to an owner of thc proprty who builds or improvcs thereon. and who dcrcs such work hinrsclf or hcrsclf or through his or her own employees, provided that such improvcmcnts are not intenclcd oroffercd for sale. If. howcrar, the building or inqtrovenrcnt is sold within onc 1tar of complction, thc Owrrcr Buildcr will have the burden of proving that hc or shc did not buikl or improve the propctty for the pur;nse of salc). _1. asowncrof thc pnrpcrly, amcxclusivclycontracting with liccnscd conlractors to construct thc prcrjcct (Sec. 7(X4, Busincss and Profbssion Codc: 'l'hc Contractor's Liccnsc Law does not apply lo an owncr of propcrty who builds or improvcs there<ln. and who contracls for such projccts with a Contractor(s) licenscd pursuanl lo the Contraclor's Liccnsc Law). _l am cxcmpt undcr Section-. B. & P.C. for this rcason. Date: WORKERS' COMPENSATION DECLARATION I hcreby aflirnr undcr pcnalty of perjury onc of thc following dcclarations: _l have and will maintain a Ccrtilicate of Consent to Sclf-lnsurc for workers' comlrcnsalion. as povided for by Section 3700 of thc Codc. for the pcrfornunce of thc work for which the pcrmit Ls issucd. and will maintain workcrs' conrpensation insurance. as rcquircd by Scction 37fi) of the Labor Code. for the performancc of which is My insurancc carricr ard policy number arc: rt74Policy _l ccflify that in thc Jrcrtbrmancc of the work for which this pernrit is issucd. I shall not employ any person in any manncr so as to beconrc subjcct to thc workcrs' compcnsation laws of Grlittrrnia. aurd agrcc that if I should bcconrc subject to thc workcrs' compcnsation provisions of Scction 3700 of the l-atnr Codc, I shall. forthwith conrply with those provisions. WARNTNG: Failurc to liccurc workcrs' compcnsation coveragc is unlawful. and shall subjccl an employer to crfuninal pcnaltics and civil fincs up lo onc hundred thousand dollars ($100,000). in addition to thc cost damages as providcd for thc Scction Corlc.altorncy's I hcreby allirnr undcr pcnalty of pcrjury that I arn liccnscd under provision 9 (comrrncing with Scrction 7000) of Division 3 of the Business and Profcssions Codc, and my license is in full force and cffcct. Liccnse D C()NSI'RUC'I'ION I,I'Nt)ING A(; I'NCY I lrcrcby sffim undcr FntrltyofFrjury thar thcrc is a construction lcnding agcrcy for lhc JErformurcc ofthe work for which this frcrmit is issucd (Scc. 3097, Civ. C.). Lrndcr's Narnc: lrndcr's Addrcss: APPLICANT DECLARATION I hcrcby allirm undcr penalty of Jrcrjury onc of thc following declarations: Dcrnolition Pcrmits-Asbcstos Notification Federal Rcgulations (Title 40. Part6) -Rcquircd lrttcr of Notificalion atxrve nrcntioncd propcrty for Applicant or Agent Pcrnrilee nanre )D lhc Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf Ioor/Ve nVl nsu I atio n Roof Sheathing Shear Wall Framing lnsulatio nlEnerqy Drywall Ext./lnt. Lath Brown Coat lVlasonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif. L/ ?-'2-/-P /Lc zi F!NAL /2. l. Ld fLC eSt t4a1 2f7 Certificate of Occupancy Notes, Remarks, Etc. L Rev. 08-07-201 5 Date:_