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BUILDING- INSPECTOR RECORD SITE-WORK DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION I hercby afftrm undcr pcnalty of perjury thlt I m cxctrpt fmm thc Contraclotr' Licmp llw for thc following rqsn (Sc.7031.5 Busincss and Pmfcssion Crxlc): Any City or County which rcquircs 8 tmit lo conslrucl, alts, improrc, &mlislf or rcIEir uy. srrcturc. prk r to its issuucc, alrc rcquircs the applicant for such lEmit to filc a signcd statemnl that hc or shc ir liccnsd pursuut io the Fovisions of tlE Contrclor's LLTn*d tlw (Chaptcr 9. Comncing wilh S$tion 7fi)0 of Division 3 of thc Busimss ud PDfessbnsCodc)orthathcorshcisexcmpttlmfromandthcbasisforthe&llcgcdcxmption. AnyviolationofScdionT03l.5bymy applicant for a Frmit subjEts thc applicant to a civil pcmlty of not mrc lhu fivc hundrcd dollds (S500). _1, as owrrcr of thc propcrly. or my cmployees with wagcs as their solc crlmpcnsalion, will do thc work and thc stnrcturc is mt intended or ofTcred for salc (Sec.7Ul4. Business and hofcssions Codc: Thc Contraclor's Liccnse [:w docs not apply lo an owncr of thc property who builds or inrprovcs thcrcon, and who docs such work himself or herself or through his or her own employces. provided thal such irnprovcrncnts arc not intcnded oroflerctl lbr salc. If. howcvcr. thc buikling or improvenrcnt is sold wilhin onc ycar of completion. thc Owncr Buildcr will have thc burdcn of proving that hc or shc did not build or improve tlrc proprty for lhc purynsc of sale). _1, as owncr of thc propcrty. am cxclusively contracting with licenscd contraclors to construct the projcct (Scc. 7W. Busincss and hofessbn Codc: Thc Contractor's License Law docs not apply lo an owncr of propcrty who builds or improves thcreon, and who contracts for such projccts with a Contractorls) liccnscd pursuant to thc Contractor's Liccnsc [:w). I am cxcmnt undcr Sc.ction . B. & P.C. for this rcason. Date:_Ormer: wo DECLARATION I hcrcby affirm undcr pcnalty of pcrjury one of the following declarations: _lhaveandwillmaintainaCcrtificateofConscnttoSclf-lnsurcforworkcrs'conr;rcnsation,as providcdforbyScction3Tfi)ofthc Labor Codc, for thc performance of the work for which the pcrrnit is issucd. Tta have and will rnaintain workers' compcnsation insurance. as rcquired by Scction 3700 of thc Labor Codc. for thc pcrformatrce of the work which this;rcrrnit is issuctl. My workers' comlrcnsa!' and plicy numbcr are:"7i ffirfi'""ranccca'irrcr Policy \\' t 'LC &""rrify ,U, in thc [rcrformmc of the vo]k for which this pcrmir is issucd I shlll not etrpby any pemn in ey mnncr $ as to becom sbjcct to thc wqtsd omlrcnslion laws of Califomis, Md agre that if I should becom subjst to llE work6s'mmJrNstionprcvisionsofScction37mofthchborCode.lslEll.fonhwithotrplywiththospEvisions. WARNING: Failure lo $curc workcrc cotrpcnstion covcmgc is unlawirl. ard shall subjLTt il mplo)€r to oiminal lEnaltics od civil fincs up to onc hundrcd thousand Section 3076 ef thc L;rlxrr Codc. interest Dare: lclt* lzo dollars ($l in addition to the providcd for thc and I hereby affirm undcr pcnalty of pcrjury that I am licensed 9 (cornrncncing with Scction 7fin) of Division 3 of the Busincss and Professions Codc, and my license is in full tilrcc and eff'cct. Licensc C.\O Nurrthcr: q1 R"l 5G, I\ ^.6.ro'I v VI W I hercby 8ffirm undcr lEnaltyof Frjury that therc is a @nslruction hnding agcrcy for lhe pcrforme of thc work for which lhis Frmit is is$ed (Sec. 309?. Civ. C.). [,cnder's Namc: Lcndcr's Adclless: APPLICANT DIICLARAT'ION I hoeby affurn undcr pcnalty of pcrjury one of thc following declarations: Dcmolition Permits-Asbcslos Notification Fcderal Rcgulations (Titlc 40. Part6) -Rcquircd lrttcr of Notification Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenUl nsu latio n Roof Sheathinq Shear Wall Framinq Insulatio nlEnergy Drywall Ext./lnt. Lath Brown Coat JVlasonry Pool Fence T-Bar Handicap Req. Deputv Final Report Engineer Final Report Flood Zone Certif . FINAL tt I L\ltto Dfr+ffi Certificate of Occupancy Notes, Remarks, Etc. Rev. 08-07-201 5 I ccrtifv that thc Nh ccnity rhat I have fcdcralrcgulations rcgarding asbcslos renrovalarc not applicable to this propct. rcatlthis abovc nrcnti<lncd propcrty ltrr Applicant or Agent Pcrnrilee nanre construction. and