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BUILDING. INSPECTOR RECORD SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcrcby affrrm undcr penalty of frcrjury that I am cxempt from thc Contractors' Licensc [-aw for thc following reason (Sec.7031.5 Business and Profcssion Code): Any City or County which rcquircs a Jrcrmit to construct. altcr, improve, dcmolish or rcpair any structure. pnclr to its issuancc, also rcquircs thc applicant for such prmit to filc a signcd statcrncnt that he or shc Ls licenscd pursuant to thc yrovisions of thc Contractor's Liccnsed l-aw (Chaptcr 9, Comrnencing with Scction 7000 of Division 3 of the Business and Profcssions Code) or that hc or shc is cxcrnpt thcrefrom and thc basls for thc allcgcd cxcmption. Any violalion of Section 703 I .5 by any applicant for a pcrmit subjcrcts the applicanl to a civil pcnalty of not morc than five hundred dollars ($500). _1. as owtrcr of the propcrty, or my enrployccs with wages as their solc conrpensation. will do the work and the surrtunc is ncrt intcnded or olTcrcd for salc (Sc.c.7044. Business and Profcssions Codc: Thc Contraclor's Liccnsc l-aw docs not apply to an owncr of the proprty who builds or irnproves thcrccln, and who docs such work hirnsclf or hcrself or through his or her own employees. providcd that such inrprovcnrcnts arc not intcndod oroflcred for salc. If, howerrr. thc building or improvcrrcnt is sold within one ycar of complctiotL thc Owrcr Buildcr will havc thc burden of proving that hc or shc did not buih or intprovc tlrc propcrty for thc purpose of salc). _1. as owncr of thc pmpcrty. am exclusivcly contracting with liccnscd conlraclors to construct the projcct (Sec. 7(W. Busincss and Protbssion Codc: The Contractor's Liccnsc Law docs not apply lo an owncr of property who builds or improves thcrcon. and wh<l contracts for such projccts with a Contracto(s) liccnscd pursuant to lhc Contractor's Liccnse taw). _l arn cxcnlpt B. & PC.this , I hereby affirrn undcr pcnalty of pcrjury one of thc following de.clarations: _l havc and will maintain a Ccrlificatc of Conscnt to Sclf-lnsurc for workcrs' compcnsation, as providcd for by Scction 3700 of the Labor Codc. for thc performance of thc work for which the permit ls issucd. _l havc and will maintain workers' compensation insurarrce. as required by Scction 3700 of the labor Codc, for thc performancc of thc work tbr which thls permit is issued. My workcrs' compcnsation insurance carricr and policy numbcr arc: Policv Number: Expircs:- -J _l ccrlily that in the pcrlbrrnarce of thc work t'or which this pcrnrit is issucd. I shall not employ any pcrson in any nunncr so as lo bcconrc subjcct to thc workcrs' conUrcnsation laws of California. and ugrce lhat if I should bcconrc subict to thc . workers' comJrcnsation provisions of Scction 37fi) of thc l-,:rtnr Code. I dull. forthwith comply with those provisions. WARNING: Failurc to riccure workers' conrpcnution covcragc is unluwful. and shall subject an cntployer to criminal pcnaltics and civil fincs up to one hundrcd thousand dollars ($1(X).UX)1. in addition to thc cosl of comJrensation. darurges as providcd for thc atlorney's I hcrcby atfirrn under penalty of perjury thal I am licenscd undcr provision of Chaptcr 9 (comnrncing with Scction 7000) of thc Busincss and hofcssions Code. and my liccnsc is in full force and cffctct. 3 Liccnse Class: Licensc Numbcr: I)tte:Conlractor:_ W I hcrcby aflirm undcr pcnalty of Frjury th0t lhcrc is a @nsruction lcnding agcrcy for thc lErforlrcc of thc rcrk for whbh lhis pcrmit is issued (Sec. 3097, Civ. C.). kndcr's Norc: lrndcr's Address: APPI ICAT\TT DT.CLARATION I hcreby aflirm undcr pcnalty of pcrjury one of thc following dcclarations: Dcmolition Pcrnrits-Asbcstos Notification Fedcral Rcgulations (Titlc 40, Part6) -Rcquircd lrttcr of Notification -l certify that thc fcdcralregulations rcgarding asbestos rennvalare not applicablc to this projc'ct. -l certify that I have read this application and state that the atnvc information is corrccl. I agree to comply with all City and County ordinances and State laws rclating to building construction. and hcreby authorize reprcscntatives of this City and abovc rncntioncd propcrty for Applicrutt or Agent Perntilee nanle // cntcr u1rrn thc Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenVI ns u I atio n Roof Sheathino Shear Wall Framing lnsulatio nlEnergy Drvwall Ext./lnt. Lath Brown Coat [\Iasonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif ,l l,l rl FINAL I 'Lu\ U wurw WJ Certificate of Occupancv I Notes, Remarks, Etc. Rev. 08-07-201 5