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BUILDING- INSPECTOR RECORD SITE.WORK DATE ID/S!G.COMMENTS OWNER BUILDER DELCARATION I hcrcby afhrnr undcr pcnalty of perjury that I am cxcmpt from thc Contractors' Liccnse l.aw for the following rcason (Sec.7031.5 Busincss arxl Profcssion Codc): Any City or County which rcquircs a pcrmit to construct. altcr. improvc. dcmolish or repair any structure, prior to its issuancc. also requircs thc applicant for such yrcrrnit to file a signcd slalemcnt that hc or she ls licenscd pursuant lo the povisions of thc Contractor's Liccnscd L:w (Chapter 9. Commcncing with Scrction 7000 of Division 3 of the Busincss and hofcssions Codc) or that hc or she is cxerrpt thercfrom and thc basis for the allcged exemplion. Any violation of Section 7031.5 by any applicant tbr a pcrmit subjccts thc applicant to a civil pcnalty of not more than five hundred dollars ($500). -1. as owner of the prof,erty, or my cmployces with wagcs as thcir sole compcnsation. will do the work and thc structurc is not intcrxlcd or ollcrcd for srlc (Sec.7044, Business and Profcssions Codc: The Contractor's Liccnse [:w does not apply to an owncr of the propcrty who builds or inrprovcs thereorL and who docs such work hirnself or hcrself or through his or her own cmployees. providcd that such improvcnrcnts arc not intcndod oroffercd for sale. ll. howerrcr. thc buiHing or irqlrovenrcnt is sold within onc )car of conrplctioru tlrc Owrcr Builder will havc thc burdcn of proving that hc or she did not build or improve Orc fnoperty for tlre purynse of salc). -1. as owncr of thc propcrty. am cxclusively c<lntracting with liccnscd contractors to construct thc projcrt (Scc. 7W, Busincss and Profession Code: The Contractor's Liccnsc Law docs not apply to an owncr of propcrty who builds or improvcs thcrcon, and who conlracts for such projects with a Contracto(s) liccnscd pursuant to thc Contraclor's Liccnsc taw). _l am excnrpt undcr Scrtion_. B. & P.C. for this reason. Owner:_ UABIEBSSqMPINSAUQN DEGI.AEAIION I hcrcby allirm undcr lEnalty of Fsjury orc of thc followitrg delestions: -l haw and will mintain s Ccnifrcatc of Consnt to Sclf-lnsurc for workcrs'@mpcnsalion, as pmvkied for bySfftion 3700 of thc Lrbor Code. for the lrcrfomre of thc work for which thc lErmir is issucd. $B,n*"na*iff *iottrinworkem'@mpcnsationinsurarcc,&s rcqutcdbySeclion3?0OofthctaborCrde,forth€psfommof thc work for which this prmit is issucd.My workcrs' cotnpcr{iation insurancc carricr and policy nunrbcr arc: ZVACVl E5.€tU0 7?\'zoPolicy liB*nn, ,nr, in lhe Jrrformrcc of thc work for which this 1Ermil is issued, I shall not employ any Frmn in any mncr s, as to bccom subjst to the workcrC cotrpcnsation laws ofCalifomia, ud agrce that ifl should bccore subjct to Ihc workerC compcnstion prcvisions ofscrtion 37m ofthc t2bor Codc, I slull. forthwith @mply with thos prcvisions. WARNING: Failure lo $curc workers' compcnstion ovmgc is unlawful, ad shall subtrl an employcr to qimiml 1Enrltier and civil dollars ($l00.mnt. in addition to lhc cost of compensation, damages as providcd for thc and attorney's I 1,..,. . I hcrcby aflirm undcr pcnalty of pcrjury that I arn liccnscd under provision 9 (comnrcncing with Sc,ction 70m) of Division 3 of the Busincss and Profcssions Code, arxl my license is in full force arxl cffect. Liccnsc C\D Nunrbcr: "l'51 st, Contrnctor:tvt W I hcrcby affirm undcr pcnalty of Jrcrjury that th@ is a conslruction hndinS agercy for the lrcrfol.tmc of tlE work for which this pcnnit is is$cd (Sff. 3097, Civ. C.). knder's Nom: Lrndcr's Address: APPLICANT DECLARATION I tucby affirmundcr pnalty of pcrjury onc o[ thc following dcclarations: Dcrnolition Permits-Asbcstos Notification Fedcral Regulatiorrs (Titlc 40. Part6) _Rcquircd lrtter of Notilication -l ccrtify lhat thc fcdcral rcgulations rcgarding asbcstos rcmovalare not applicablc to this project. N?.""ify that I have rcad this application and statc that the atnvc information is correct. I agrc.e to corrrply wirh all City and County ordinances and Statc [:ws rclating construction. and hcrcby authorize rcprcscntatives of this City and County to upn the above nrcntioncd propcrly for Agllllicant or Agr:nt IDermilee name lu I A^LV Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenVl nsu I ation Roof Sheathino Shear Wall Framing lnsulation/Energy Drywal! Ext./!nt. Lath Brown Coat J\Iasonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif. a ,W 42fr ,/2 )aaHn '- 6 frg-tt l^' I Certificate of Occupancy Notes, Remarks, Etc. Rev. 08-07-201 5 2.&r l{L./r**f\ FINAL / \t;U'