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BUILDING. INSPECTOR RECORD SITE-WORK DATE ID/SIG.,,COMMENTS OWNER BUILDER DELCARATION t I hereby atlirm under pcnalty of perjury that I am exempt from the Contractors' License [:w for thc following rcason (Scc.7031.5 Busincss and Profcssion Codc): Any City or County which requircs a pcrnrit to construct. alter, improvc. dcnrolish or rcpair any structure, prior to its issuance, also rcquircs thc applicant for such pcrrnit to filc a signed statenrcnt that hc or shc ls liccnscd pursuiult to thc provisions of the Contractor's Licensed [:w (Chaptcr 9. Commencing with Section 7000 of Division 3 of the Busincss and Profcssions Codc) or that hc or she is excmpt thcrefrom and thc basis for thc allcged exemption. Any violation of Section 7031 .5 by any applicant lbr a permit subjccts the applicant to a civil pcnalty of not more than fivc hundrcd dolkus (5500). -1, as owncr of thc proF,crty. or my cmployces with wagcs as thcir solc compcnsation. will do thc work and tltc stnrcturc is not intendcd or offered for salc (Sec.7OC+, Business and hofessions Code: The Contraclor's License l,aw docs not apply to an owncr of the pnrpcrty who builds or improvcs thcrcrrn. and who docs such work hirnself or herself or through his or her own entployccs. providcd that such improvenrcnts arc not intcndod oroffcred for sah. If, howerar. thc building or inprovcnEnt is sold wilhin one )ryu of cornpletion. thc Owncr Buildcr will havc thc burden of proving that he or she did not buih or irnprove tlrc prcprty for thc purynsc of sale). V\W as owncr of thc proFrcrry. amcxclusivcly conrracting with licensed contracrors lo conslruct thc protrt (Scc. 7O14, Business and Profcssion Codc: Thc Contractor's Liccnse Law does not apply to an owncr of property who builds or improvcs thcrcon, and who contracts for such;nojccts with a Contracto(s) liccnscd pursuant lo thc Contraclor's Licensc Law). _l am excmpt undcr Section_, B. & P.C. for thls reason. WORKERS' COMPENSATTON DFCLARAT']ON I hcrcby atlirrn undcr pcnalty of prjury onc of thc following dc.clarations: _l have and will nuintain a Ccrtificate of Conscnt to Self-lnsurc for workcrs' compensation, as povidcd for by Scction 3700 of the [:bor Codc. for thc pcrformance of the work for which thc permit ls issued. _l havc and will maintain workers' comJrcnsation insurance. as rcquirct by Scction 3700 of thc labor Codc. for the pcrformance of thc work for which this pcrmit is issucd. My workers' compcnsation insurance carricr and plicy numbcr arc: Carricr: Policv Numbcr: Exoires: lrbt""rtify thar in thc pcrformarrce of thc work for which this permit is issued. I shall not cmploy any pcrson in any tnanner so as to bcconrc subjcct to thc workcrs'compensation laws of California. and agrcc that if I slxluld bccornc subjcct to thc workcrs' compensation provisions of Section 37fi) of thc latnr Codc. I s]rall. forthwith comply with thosc provisions. WARNING: Failure lo liccurc workcrs' compcnsation coverage is unlawful. and shall subjcct an employer to crirninal pcnaltics and civil fines up to onc hundrcd lhousand dollars (S100.O00). in addition to thc cosl of compcnsation. danragcs as provided for thc a Section 3076 of thc Latxrr Code. intcrest and altorney's fces. Dare: -7 ( ?u I to Applicarrt: LICENSED CONTRACTOR DECI ARATI(IN I hercby affirrn undcr pcnalty of grerjury thal I am licenscd under provision of Chaptcr 9 (comnrncing with Scction 7000) of Division 3 of thc Busincss and Professions Code, ard my licensc is in full force and cffect. Liccnsc Class: Liccnsc Nurnbcr: Date:-- CONSTRUCTION LENDING AGENCY I hcrcbyaflirmurdcrlEnaltyof lrcrjurythal thcrcisaconstruction lcndingagercyforthepcrfomcof thcrcrkforwhichthisFrmit b issucd (Se. 3097, Civ. C.). Lrndcr's Nanrc: Lcndcr's Adtlrcss: APPLICANT DF'CLARATION I trcrcby aflirnr undcr penalty of pcrjury onc of the lbllowing dcclarations: Dcmolition Pcrnrits-Asbcstos Notification Federal Regulations (Titlc 40. Part6) '--Rcquircd [.cttcr of Notifrcation -l ccrtify thal thc fedcral rcgulations rcgarding asbcstos rcnrovalare not applicablc to this projcct. E\ ccrtify that I havc rcad this application and statc that thc atnvc inforrrution is correct. I agee to comply ordinanccs and Statc [:ws rclating to building construction, and hcrcby authorizc rcprcscntatives of this City with all City and County and County to cnter upon thc above nrentioncd propcrty for purr)ses. Applicant or Agent Itcrrttilu. rranrr)/) ,r^r^.?( L\\ z-D Set Backs \ln -G r)n ^Uai 1 Forms/Steel/Holdowns ?ltl - | L,v lJr \.,,, f t Erection Pads UFER Ground SLAB Floor S u bf loor/VenVI ns u I atio n Roof Sheathinq Shear Wall Framing lnsulatio nlEnergy Drywall Ext./lnt. Lath Brown Coat lt/asonry Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif I I ,./-a FINAL tt/wl -{/W,illra 7.62 Certificate of Occupancy Notes, Remarks, Etc. Rev. 08-07-201 5 Conlractor:_