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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION i hoeby aflirrr undo penalty of pgjury thal I an crempt from lhe Contraclore' Licrue Larv for the following reen (56.70] 1.5 Rusinss md Prof6sion Code): Any City or County rvhich requira a pmnit to construcl. alts, improve. dmolish or repair my structue. prior rc ils issuance, also requirG thc applicant for such pennit lo filc a signsl statemot lhat he ot she is licwd pmumt to the provisions of th€ Contractor's Licensed l-aw (Chapts 9, Cornmencing with Section 7000 of Division 3 of the Busines and ProfessionsCodc)orlhathcorsheisexemptthqefiomodtheb6isfortheallegcdexmption. AnyviolalionofSotionT0-1l.5byany applicantforapmnitsubjectslhe applicanlloacivilpenaltyofnotmotelhanfivehun&eddollils($500). I. a cuner oflhe prope(y. or my employs wilh u,ag6 a thet $le cdnpensalion. will do lhc work od the slruclw is nol intoded or offoed for sle (Sc.7044. Buines md hofmrom Code: 'l-hc Conlractor's Licflse Law do6 nol apply to il oMs ot lhe pmpert) u,ho builds or improvs thsmn. ud *'ho doe such \rcrt himself or hmclf or tlrough his or ho own employee. provided that such imFrovanents rc not intodcd or offqed for ele. If. hoswo, thc tuilding or improvonent is pld rvithin one yw ofcompletion. the Own6 lluildq will have the hrdo ofproving that he or she did not build or improve thc pmp€ty for the purpor of ele). ___ l. m owle oflhe propfiy. on exclusively conlracling with licensed conlracloB to connrud the pr(iecl (Sec. 7M4. BNins md hofesionCodc: nrcContractor'sLiccnsel,awdo6notapplyloanowilerofpropenywhobuildsorirnprovesth6on. and *lro connacls for such projecls uilh a Conlraclo(s) licssed pursuiut lo lhe Conlraclor's Licmsc l-aw). I m erempt undq Setion-. B. & P.C. for this reson. l)atc: DECLARATION I hereby amrm und6 penalty ofpojury one ofthc following declaations: Yif;ve mrl will maintain a Cerrificate of Consmt to SelfJmue for workos' compqsation. 6 providcd for by Strrion 3700 of thc tnbor Code, for lhe pgfommce of the work for which the pmnit is i$ucd. 2( haue and will maintain workm compcmation insurance, d required by Setion thc work for which this pqmit is isued. My workfi' compeNtion ireurmce cuis 3700 of the kbor Code. for the psfommce of anrl policy numbs ile:Fwot?tu s-t -"9 cffiry lhat in lhc performance ofthe work for which this pennil is issucd. I shali not employ any pcrson in any mmncr s 6 to beomc subjsl to lhe *ork6'compensation laws ofcalifomia. and agre that ifl should becornc subjct to the work6' compmarion provisioro of Salion 3700 of thc tabor Code. I shall. forthwith comply with lhos provisions. WARNINC: Failure to wuc rvorkffi'compmsalion coveage is unlarvful. md shall subject an mrployo to oiminal poaltia m(t civil lines up to onc hundrcd thousmd dollus ($100,000). in addition lo lhc cost of compemation. danages a providcd for the Section 3076 of the Labor Code. intdst ild attomey s fe6. l-t6- 1q I hereby aflim undo lutalty o f pojury that I an licosql under of('hapls 9 (commerrcing rvith Section 7000) ofDivision 3 of the Businss md Profsions Code. md rny licose is in full force ard cflect. License Class C3 lsb 1b7 tz- I, I hoeby affirm undu ptrahy of perjury that th6e is a coNlruction lmding agocy for the pcrfonmce of the work for which this pqnit is issued (Se. 3097, Civ. C.). Lender's Name: Lender's Address: APPLICANT DECLARA ION I hodry affnn undcr penahy or'perjury one ofthe following d6ldations: Dcmolition Pmits-Asb6los Notification Fedqal Rcgulations (Title 40. Pa(6) Required Letl6 of Nolifi cdion _l colify that the fedqal regulations reSuding 6b6tos rmovalare not applicable to this prejet. _ -_l ccrtiry that I have rcad this application md state lhat the above infomdtion is corect. I agre to cornply with all City and County ordinances ild Slatc l-aws rclating to building construction, ild hereby authorize rcprsentatives oflhis City ild Counly to entd upon lhc atrrve mcntioned propmy for inspstion Applicsn( or Agent Pcrmitce ormc (pritrt):cot) -t6 -t/ Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Subfloor/VenVlnsulation / / Roof Sheathinq I /6 Dz rJs ru fr?toy Shear Wall Framinq lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif II tt ,a FINAL qrfil'fl)l{l r[Wffit ffi/ Certificate of Occupancy I Notes, Remarks, Etc.