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BUILDING- INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWN I.:R IT UTI,DICR DD,LCA RATION I hcrebl'affrnr under penalty of perjury that I am exempt from the Contractors' Licensc law for the following reason (Set'.7031.5 Business and Prol'ession Code): Any City or County which rcquires a Jrermit to construcl, alter. improve, demolish or rcpair any structure, prior to its issuance. also requires the applicant for such permit to file a signed staternenl that tre or she is licenscd pursuant to the pmvisions of the Contractor's l,icensed l:w (Chapter 9. Comrnencing with Section 7fiX) of Division 3 of the Business and Prot'essions Code) or that he or she is exempt therefrom and the basis for the alleged excmption. Any violation of Section 7031 .5 by any applicant for a pennit subjects the applicant to o civil penalty of not more than five hundrcd dollars ($5001. _1. a.s owner ol'thc propcrty, or my employecs with wagcs as thcir sole comgrensation, will do the work and the structure is not internlal or offered for sale (Sec.7M+, Business and Pnrfession.s Code: The Conlraclor's License Law does not apply lo an owner of the pmperty wlxr builds or improws thermn and wlxl dtx.s such work himself or herself or through his or her own employees. provided that such improvcrnents are mt intended or ollcrcd for sale. Il, however. thc building or inprovenrnt is soH within one )tar of conpletiot\ thc Owner Buildcr will have thc burtlen of proving that lrc or she did not buikl or impmvc the propaty for thc purposc of s.rle). _1, as owner of thc propcrty, am exclusively contracting with licenscd conlraclors to construct thc project (Sec. 7O{4, Busincss arxl hrrtesskn Code: The Contractor's License Law drrcs not apply to an owner of prolrcrty who builds or improves thereon. and who conrracts [or such projects with a Contractor(s) licensed pursuant to the Contractor's License Law). -IantexemptunderSection-,B.&P.C.fbrthisreason. Dale: WORKI.)RS' COMPENSA'IION DECLARATION I hercby allirm undcr Jrcnalty of perjury one of thc lbllowing declarations: _l have ard will nrainlain a Certifrcate of Conscnt to Self-lnsure for workers' comyrnsation, as provided for by Section 3700 of thc Labor Code. for thc Jrcrformance of the work lor which thc prmit is issued. _l have and will maintain workers' compcnsation insurance, as required by Section 3700 of thc [:bor Code, for the performarrce of thc work \which this Jrcrmit is issued. My workers' compcnsation insurancc carricr arxt Jxrlicy numher are: a Policy U-L( - L( _l certity thut in thc Jrcrformance of the work for which this pcrmit is issued, I shall not enrploy any person in any manncr so as to bccorr suhjcct to the workers' compensation laws of California. and agrec that if I slnuld become subject to the workers' conrlrcnsation provisions of Section 3700 of the l-abor Code, I strall, forthwith comply with those provisions. WARNING: Failurc to secure workers' c'ompensation is unlawful.shall subjcct an employer to criminal Jrcnahics and civil fincs up to one hundred thousand dollars addition to of damagcs as prortrded for thc Section 3076 of the l:txrr Ctxle, interest and o"*,6i -2 7, I hcrcby al'lirrn undcr pnalty of perjury that I arn liccnscd 9 (cornmencing with Section 70m) ol'Division 3 of thc Bu.sincss and Profcssions Codc, and nry liccnsc is in full tbrcc and elfcct. a2 ILicensc CONSTRI.'CTION I,I.:NDING AGENCY I hercby allirnr under penalty of perjury that there is a construction lending agency tbr the Jrcrformance of the work for which this permit ls issued (.Sec. 3097, Civ. C.). lrnder's Name: lrnder's Address: APPLICANT DECLARATION I My affrm under penalty of perjury one of the following declarations: Demolition Permits-Asbestos Notification Federal Regulations (Title 40, Part6) -Requ ired lrtter of Notification _l certity that the federal regulations regarding asbestos removal are not applicable to lhis pr<rjcct. this and state that the above inlormalion is correct. I agree to conrply with all City antl County authorize representatives of this City and County to enter uF)n thc atxrvc mcntioncd proSrcrty lbr Applicunt or Agcnt Pernriler nanre o*", €l*2-)'- Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bf loor/Ve nVI n su latio n Roof Sheathinq Shear Wall Framinq lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat N/asonry Pool Fence T-Bar Handicap Req. Deputv Final Report Enoineer Final Reoort Ffood Zone Certif t/ FINAL //-2q- a ,44-/9 ue/ldE 'ov Certificate of Occupancv Notesr Re.marks, Etc.t /C I "f'-{ /1./ Rev. 08-07-2015 orrc, €{*l-2-O