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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 loo r/VenUl ns u I atio n Roof Sheathino Shear Wall Framinq lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat lMasonry Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif FINAL ll-2f,20 e I)eL;fz QZ) Gertificate of Occupancy Notes, Remarks, Etc. OWNER BUILDER DELCARATION D I hcrchy affirm undcr pcnalty of pcrJury that I am cxcmpt from thc Contractors' Liccnsc Law for rhe following reason (Sdc.7031.5 Busincss and Profcssion Code): Any City or Ccunty which rcquircs a pcrmit lo conslnrct. altcr. improvc. demoli.sh or repair any structurc. prior to its issuance, also rcquircs the applicant for such pcrmit to ['ilc a signcd statcrncnt that hc or she is licenscd pursuant to the provisions of thc Contractor's Licenscd Law (Chapter 9. Commencing with Section 7000 of Division 3 of the Business and Prol'cssions Codc) or that he or shc is cxcmpt theretiom and thc basis for thc allcged excmption. Any violation of Scction 7031 .5 by any applicant for a pcrmit subjccts thc applicant to a civil penalty of not morc than five hundred dollars (5500). __1, as owncr of thc property. or my employccs with wages as thcir sole contJrcnsation. will do thc work and thc stnrcturc is rnt intendcd or otTered for salc (Sec.7044. Busincss and Professions Code: Thc Contractor's Liccnsc law does not apply to an owncr of the prcpcrty who builds or improves thcrcon. and who does such work himself or herself or through his or hcr own employccs. providcd that such improvenrcnts arc not intcrdcd oroflered for sale. If, howc'rcr, thc building or inprovcnrcnt is sold within one )rar of conphtiou thc Owncr Buildcr will have thc burdcn of proving that hc or shc did not buiH or improve thc propcrty for thc purynsc of sale). l. asowncr of thc pmperty. anrcxclusivcly contracting with liccrrscd conlraclors to construct thc project (Scc. 7044, Busincss and Professbn Codc: 'I'hc Contractor's Licensc Law docs not upply to an owncr of progrcrty who builds or improves thcrcon, and who contracts for such p<rjccts with a Contracto(s) liccnscd pursuant to the Contraclor's Licensc hw). -l arn cxctnpt under Scction-, B. & P.C. for this rcason. Dale:Owner: womrns'co DECLARATION I hercby affirm under penalty of Jrcrjury one of the following dcclarations: _l havc and will maintain a Ccrtificatc of Conscnt to Self-lnsure for workers' comgrcnsalion, as povidcd for by Section 3700 of thc I-abor Code. for the pcrfornunce of the work for which the permit ls issued. _l have and will rnaintain workers' compensation insurance. as required by Section 3700 of thc Labor Codc, for the pcrformance of the work for which this pcrmit is issucd. My workers' compensation insurance carricr and plicy numbcr arc: _l cerrify that in thc pcrformarrcc of the work for which this pcrmit is issucd, I shall not cmploy any pcrson in any trurnncr so as to bccome subjcct to the workcrs'conqrcnsation laws of Califomia. and agrcc that if I should bcconr subjcct to thc workers' compensation provisions of Scction 3700 of the L:bor Codc. I shall, forthwith comply with thosc provisions. WARNING: Failurc to securc workcrs' compcnsation covcragc is unlawf'ul. and shall subjcct an entploycr to criminal pcnaltics and civil fincs up to onc hundred thousand dollars ($100,000). in addition lo thc cost of cortqrcnsation. damagcs as providcd for thc Scction 3076 of thc [:tnr C-ode. intcrcst and attorncy's fees. Date: Applicant LICBNSED CONTRACTOR DECI ARATION I hcrcby atfrm undcr pcnalty of perjury that I am licenscd under provision of Chapter 9 (comnrncing with Scction 7000) of Division 3 of the Business and hofessions Code. ard my liccnse is in full force ard effc.ct. Liccnsc Date: Nurnbcr: Contraclor:_ Policv Nurnbcr: Exoires: lrndcr's Address: W I lEreby .ffrm urdcr JEnalty of lErjury that ttm is a consruction lcnding 8gcrcy for the pcrformc of thc mrk for uhich lhis tEmit is issed (Ss.3097. Civ. C.). Lrrrdcr's Nanrc: A PPLICA NT NF'CLAIIA TION I hcrcby aflirm undcr pcnalty of pcrjury one of thc following dcclarations: Dcmolition Permits-Asbcstos Notification Federal Regulations (Titlc 40. Part6) -Rcquircd lrttcr of Notification _l certify that thc f'cdcralrcgulations regarding asbcstos rcnxrvalarc not applicablc to this projcct. _l ccrtify that I havc read this application arxl slale that the atnvc information and hcrcby authorize is corrcct. I agrcc to comply ,representativcs of this City with all City and County and cntcr upon thcordinanccs and State [:ws rclating to abovc nrclttioncd .rpplicant or r\genl Permiler nnnre Rev. 08-07-2015