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BUILDING. INSPECTOR RECORD SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcreby affirm under pcnalty of pcrjury that I am cxenrpt from thc Contractors' License l.aw for the following reason (Scc.7031.5 Busincss and Profession Codc): Any City or County which requircs a prmit to conslruct. alter. improve. dcmolish or reJnir any structurc, prior to its issuancc, also rcquircs the applicant for such prmit to filc a signcd statement that hc or shc is liccnscd pursuant to the provisions of thc Contractor's Licenscd law (Chapter 9. Commencing with Section 7000 of Division 3 of the Busincss and Prol'essions Codc) or lhat hc or shc is excmpt thcrefrom and thc basis for lhe allcged cxemption. Any violation of Section 7031.5 by any applicant lor a permit subjccts thc applicanl to a civil penalty of not morc than fivc hundrcd dollars ($500). --1. as owrrcr of the propcny. or my ernployces with wagcs as thcir solc conrpcnsation. will do the work and thc stnnurc is rx)t intcndcd or ofl'crcd for sale (Scrc.7044, Busincss and Profcssions Ccxlc: Thc Conlraclor's License [:w does rrot apply to an owner of thc propcrty who builds or improvcs thercnn, and who docs such work himsclf or hersclf or through his or her own employecs. providcd thal such improvcnrcnts arc nol intcrxlcd or ofl'crcd for salc. If. howewr. thc building or inproverrcnt is sold wilhin one )rcar of complction, thc Owrcr Buildcr will have thc burdcn of proving that hc or she did not build or improvc thc ptopcrty for thc purynsc of sale). __1, as owncr of the property. am cxclusively contracting with liccnscd contraclors to conslruct thc projc.ct (Scc. 7O14. Business and Profession Code: The Contractor's Licensc Law docs not apply to an owner of propcrty who builds or improves thcrcon, and who contracts for such pojccts with a Contracto(s) liccnscd pursuant to the Contractor's Liccnse taw). _l am excmpt under Section_. B. & P.C. for this rcason. I ):rlc. ( )u ncr: WORKERS' COMPENSATION DECLARATION I lrcreby alf irm undcr pcnalty of pcrjury one of thc t'ollowing dcclarations: _l have and will maintain a Certificatc of Conscnt to Sclf-lnsurc for workers' compcnsation. as provided for by Scction 3700 of the l-abor Code. for thc lrcrformancc of the work for which thc prmit is issued. _l have and will maintain workers' conrpensalion insurarrce, as rcquired by Scction 3700 of thc Labor Code, for the lrcrformance of thc work for which this 1rcrmit is issuod. My workcrs' comlrcnsalion insurance carrier and Snlicy numbcr arc: Pohcv Numbcr: Exnircs: _l ccnify that in the pcrformance of the work for which this permit is issued, I shall not employ any person in any manncr so as to bccome subject to thc workcrs' compcnsation laws of California, and agree that if I should bcconrc subjcct to thc workcrs' compcnsation provisions of Scction 3700 of thc labor Code, I shall. forthwith comply with those provisions. WARNING: Failure lo sccurc workers' compcnsalion covcrage is unlawful, and shall subject an cmploycr to criminal Jrcnaltics and civil fines up to onc hundrcd thousand dollars ($100.fin1. in addition to the cost of compcnsation. danragcs as providcd for thc Scction 3076 of lhc Lahrr Code. inlerest and attorncy's l'ccs. Dil", lcl '21 - h)Zc) I hcrcby aflirnr undcr Jrcnalty of pcrjury that I anr Chaptcr 9 (comnrcncing with Scction 7000) of Division 3 of thc Business and hofessions Code, ard my liccnse is in full forcc and cffcrt. l-icensc c) o*", l0 " <,,1- Zd - I hcrcby aflirm undcr lEnalty of Frjury that thw is a snstruction lcnding agcrcy for lhc pcrfornucc of Ihc work for which this Frmit is rssucd (Sa. 3097. Civ. C.). Lcndcr's Narrrc' lrndcr's Adclrcss: APPLICANT DECLARATION I lrocby aflirm undcr penalty of perjury onc of thc following dcclarations: Dcmolition Pcrmits-Asbcstos Notification Fcderal Rcgulations (Titlc 40. Par16) _Rcquircd [rtter of Notilication _l ccrtify that the fcdcral rcgulalions regarding asbestos rcmovalarc nol applicablc to this proi.ct. _l ccrtify that I havc rcad this application and statc that thc atnvc inforrnation is corrcct. I agrcrc to conrply with all City and County rcpresentatives of this City and County lo entcr uprn theordinanccs and Statc laws relating to construction. and hcreby authorizc abovc rncntioncd property for Applicant or Agent Pernrilec name ( print): purposcs. Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bf loor/VenUl ns u I atio n Roof Sheathing Shear Wall Framing lnsulation lEnerqy Drywall Ext./lnt. Lath Brown Coat [\Iasonry Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Fanal Report Flood Zone Oertif .t'I ,tl rt^,,^--d .>Otjr /frf7{///nfi{4 r l,Plt4r J,tl,Ttal t'Jq v l,^l/, FINAL l;4ry,/t/4 ryO4/a&idr Certificate of Occupancv Notes, Remarks, Etc Rev. 08-07-201 5 , 2'1*e \ ,,r",fr.2 1-LA