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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BT'ILDER DELCARATION I hcrcby alfrm under penslty of lEriury that I m cxempt fmm tlE Conirac{ors' Liens Liw for the following rqsnr(Ss.*031.5 Busincss and Prcfession Codc): Any City or County which rcquircs s lrcmit to construct, alts, improvc, &mlish or rctEir my r srructre. prior to its issuilcc. also rcquircs thc applicant for such JErmil to filc a signcd stalcmnt that hc or slE is liccnsd pusust to thc Fovisions of thc Contractor's Liccnscd lrw (Chaptcr 9, Commrcing with Setion 7000 of Division 3 of the Busircss md ProfcssionsCodc)orthathcorshciscrcmptthcrcfromandthcbssisforthcallegcdercmplion. Anyviol.tionofsetionT03l,5byrny applicsnt for a pcrmit subjets thc applicant to a civil pcmlty of not mrc thm ftvc hundrcd dollss ($500). _1, as owncr of the propcrty. or my cmployccs with wagcs as thcir sole mmpcnsation. willdo thc work anl thc stnrttre is not intcndcd or offercd for salc (Se.c.7044. Business and Profcssions Code: Tltc Contractor's Licensc law does not apply to an owncr of thc pnrpcrty who builds or improves thercrrn. and wh<l docs such work hinrself or hcrself or through his or her own employecs, providcd that such inrprovcrrrcnts arc not intendcd oroffcrod frrr salc. If. tnwer,cr. thc building or in5rrovcrrrnt is sold within onc )rcar of conrphtion. thc Owrcr Buildcr will havc thc burdcn of proving thal hc or shc did not buikl or improvc tlrc propcrty for lhc purynsc of salc). _1, as owner of the propcrty, am cxclusively contracting with liccnsed contractors lo conslruct thc proircl (Scc. 7014. Business and Professkm Codc: The Contractor's Liccnse Law docs not apply to an owncr of property who builds or improvcs thcrcon. and who contracls for such projccts with a Contractor(s) licenscd pursuant to thc Contraclor's Liccnsc l-aw). _l am cxcmpt undcr Sc.ction-. B. & P.C. for this reason. Owner:- WORKER.S' COM PENSATION DFCLARATION I hercby atTirm undcr pcnalty of pcrjury onc of the following dcclarations: _l havc and will maintain a Ccrtificatc of Consent to Sclf-lnsurc for workcrs'cornpcnsation. as providcd for byScction 3700 of the Labor Codc. for the pcrformancc of the work for which thc prmit is issued. _l havc and will maintain workcrs' cornpensation insurancc. as rcquircd by Section 3700 of thc [abor Codc. for thc perfonnancc of thc work firr is issucd. My number are:( {Vqr>o+-Zo-Zt O a 1t \LoPolicy _l certify that in the pcrforrrunce of thc work for which this permit is issued. I shall not cmploy any person in any rnnncr so as to bcconrc subjcct to thc workcrs' compcnsation laws of California. and agrcc that if I should bcconrc subjcct to thc workcrs' cornpensation provisions of Section 3700 of thc l-:bor Code. I shall. forthwith comply with thosc provisions. WARNING: Failurc to sccurc workers' compcnsation coverage is unlawful. and shall subjcct an enrployer to crirninal penalties and civil lines up to onc hundrcd thousand dollars (S100.m0). in addition to thc cost of damagcs as providcd f'er the ,::::"'f;riliT;'"*" and altorncy's fecs. t I hercby affirnr undcr pcnalty of grcrjury lhat I ant liccnscd undcr of thc Busincss and hofcssions Codc. and my liccnse is in full Chaptcr 9 (cornrncncing with,Scction 70m) of Division 3 and effcrct. Liccnsc . c-ro e_ \G Nunrbcr:t I hcrcby alfirnr undcr pcnalty of pcrjury that lhcrc is a construction perfornmnce of the work for which this permit is issucd (Scc. 3097. Civ. C.). l-cnder's Namc: lrndcr's Address: APPLICANT DECLARATION I hucby aflirm undcr pcnalty of pcrjury onc of thc following dcclaratiotts: Derrrolition Perrnits-Asbcstos Notification Fcderal Rcgulations (Titlc 40, Part6) _Rerluircd Lcttcr of Notification _l ccrtify that lhc fcdcral rcgulations rcgarding asbcstos rcnxrval arc not applicablc to this projcct. )<-f certify thal I have rcad this application and state thar thc ls agrc'c to comply with all City and County ordinanccs and Statc Lrws rclatirrg to building of this City and County to cnter upon thc abovc nrcntioncd propcrty for Applicant or Agent Perntitee nnnre Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loo r/VenVl nsu I atio n Roof Sheathing Shear Wall Framinq lnsulation/Energy Drvwall Ext./lnt. Lath Brown Coat [\Iasonry Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flqod Zone Certif I >oVt,klfrhYVfif l';/,/Eo )$y,xt*.f:c,rt FINAL dflfto )fuilooJ''Jq Certificate of Occupancy Notes, Remarks, Etc. --? Rel,. 08-07-201 5 a.a C ,rr"'t lo / 2o f eC\ contracro'I(- *," I plulr'. N, ,wC<