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BUILDING- INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcrcby offrm undcr pcnalty of Frjury that I m cxcopt from thâ‚¬ ContractoN' Liccnsc [:w for lhG followirg romn (Sc.70313 Busincss ard Prcfcssion Code): Any City or County which rcquircs a lrcmit to mnstruL ahcr, improvc. dcmlish or rcIEir uy ' stnrturc, piln to its issumc, also rcquircs thc applicunt for such trrmil to lilc I signed staterent that hc or slE is liensd pusuel to the Fovisions of tlE Contmctor's Licen$d bw (Chapter 9. Commrcing with Sstion 7000 of Division 3 of thc Busiress ild Profcssbns Crde) or that hc or shc is cxctrpt thcrcfrom ard thc basis for thc allcged cxcmption. Any violation ofsectbn ?03 1.5 by any. alplicant for a pcrmit subjEts thc applicant to a civil pcmlty of not mrc thu fivc hurdrcd dollrs ($500). I _1. as owrrcr of the prof,crty. or my cmployccs with wagcs as their solc compcnsation, will do the work and the structurc is not intcndcd or offcrcd for s:rlc (Scr.7044. Busincss and Prcl'cssions Codc: 'lhe Contractor's License [.aw does not apply to an owner of thc proFrrty who builds or improvcs thercon. and who does such work himself or herself or through his or her own employees, providcd that such improvcnrcnts are not interxlod oroffercd for sah. lf. howcrrcr. thc buiHing or inprovenrnt is sold within one )rcar of comphtion, the Owner Buildcr will havc thc burdcn of proving that hc or shc did not build or improve the proSrty for tlrc purpose of sale). _1. as owncr of thc propcrty, am cxclusivcly conlracting with liccnscd contractors to conslruct thc proi'ct (Sec. 7044. Busincss and Profcssion Codc: The Contractor's Liccnse Law docs nol apply lo an owncr of propcrty who builds or improves thercnn, and who conlracts for such proicts with a Glntract<l(s) liccnsed pursuant to thc Contractor's License [aw). -l amexcmpt under Section-, B. & P.C. for thls rcason. I)ale:( )w'lrcr: WORKERS' COMPENSATION Dr.CI ARATION I hcreby affirm under pcnalty of grcrjury onc of thc following dctlarations: -\por" and will maintain a Cerrificatc of Consent to Sclf-lnsure for workcrs' compcnsation, as povidcd for by Scction 3700 of thc Latrdr Code, for thc pcrfornurncc of thc work for which thc pcrrnit is issued. _l have and will maintain workcrs' corrrpcnsation insurancc, as requircd by Scction 3700 of the Labor Code, for the perforlnatrce of thc work for which this pcrmit is issucd. My workcrs' conrpcnsation insurancc carricr and policy number are: J"- Policy lt /2-) _l certify that in thc pcrformarcc of thc work for which this pernrit is issucd. I shall not employ any person in any rnnncr so as to bccome subict to the workcrs'compcnsation laws of California. and agrce that if I should beconrc subject to thc workers' compensation provisions of Scction 3700 of thc [-atnr Codc. I shall. forthwith cnmply with those provisions. WARNING: Failure to sccurc workcrs' civil fines up to onc hundrcd thousand comlrcnsation covcrage dollars ($100.0fi)). in ts shall subjcct an employcr to criminal pcnalties and addit ion cost of comFrcnsation. danrages as providcd for thc Scction 3076 of thc intcrcst arxl atlorncy's ,12 Applicant: LICENSED CON'I'RACTOR DI.'CLAItA'I]ON I hcreby affirm under pcnalty of perjury thal I am liccnscd undcr provision of Chaptcr 9 (comnrcncing with Section 7000) of Division 3 of the Business and hofessions Code. alrd rny liccnse is in full forcc and effcrct. L 1 lo o 67" Liccnsc ('ontructrlr: W I hcrcby oflirm undcr Jrcnalty of lErjury lhat thcrc is I s)nsruction lcnding {gcrcy for thc lErforrucc of the work for which this ]rcrmit is issucd (Sec. 3097. Civ. C.). Lcndcr's Namc: lrnder's Address: APPI ICANT DECLARATION I lrcrcby affirm undcr pcnalty of perjury onc of thc following dcclarations: Dcrnolition Permits-Asbcstos Notification Fcdcral Rcgulatiorrs (Titlc 40, Part6) -Requircd [-ctter of Notification _l certify that thc fcdcral rcgulations rcgarding asbcslos rcmovalare not applicablc to this projc',ct. statc that thc ahrvc infornurtkrn is corrcct. I agrcc to comply with all City and County and hcreby authorizc reprcsentatives of this City and County to enter upn the above nrcntioned property for Applicant or Agent t Pernritee name (print):__ purposcs. Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenVI nsu Iatio n Roof Sheathinq Shear Wall qr.c.l .2d rL6 7A Framinq !nsulatio nlEnergy Drywall Ext./lnt. Lath Brown Coat J\Iasonrv Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif. FINAL /Z-l-fr P CrS /,)etj ry4 Certificate of Occupancv J Notes, Remarks, Etc. Rev. 08-07 -201 5 nere: irlt4/^)l' t