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BUILDING- INSPECTOR RECORD SITE.WORK DATE ID/SIG COMMENTS Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/Ve nUl n su I atio n -l r Roof Sheathinq ll ,0 Dq-*Y/ Shear Wall I Framinq lnsulatio nlEnerqv Drvwall Ext./lnt. Lath Brown Coat Nlasonry Pool Fence T-Bar Handicap Req. Deputy Final Report Enqineer Final Report Flood Zone Certif tl \^t)4 (,/Ul{tdo,/FINAL Certificate of Occupancy t Notes, Remarks, Etc. I hereby affirm undcr penalty of perjury that I am exempt from tlrc Cbntracton' License [-aw for the following reason (Sec.7031.5 Busincss and Profcssion Code): Any City or County which requires a pcrmit to construcl, aller, irnprove. dernolish or rcpair any structure, prior to its issualrce. also requires the applicant fkrr such pernilt to file a signed staterrcnt that he or she is licenscd pursuant to thc pmvisions of thc. Contractor's l,icensed l:w (Chapter 9. Commcncing with Section 7fiX) of l)ivision 3 of the Business and Prot'essi<lns Code) or that he or she is exempt therefiom and tlre basis for tlre alleged exemption. Any violation of Section 703 I .5 by any applicant for a pennit subjects thc applicant to a civil penalty o[ not more than llve hundred dollars ($5tXl1. of thc propcrty, or my employecs r*,ith wages as thcir solc compcnsalion, will do the work and thc slructurc is rnt or offeretl for sale (Sec.7M4. Business and Professions Code: The Contraclor's License Law does not apply to an owner of the propcrty who builds or ingows therooq and wtxl does such w<lrk himself or hcrself or through his or her own employees, provided that such irnprovernents are not intended or ollercd for salc. Il. however. the building or improvcment is sold within one )€ar of conpletion, the Owner Builder will havc thc burden of proving ttut hc or she did not buikl or improvc thc p.perty for tlrc purporc of sale). _1. as owner of the prcperty, am cxclusively contracting with liccnsed conlracloni to conslruct thc pr,oject (Sec. 7044. Busincss and Pnrtbssirxr Code: The Contractor's License Law does not apply to an owncr of progrcrty who builds or improves thereon. and who contracrs for such projects with a Contractor(.s) licenrcd pursuant to thc Contractor's Licensc l-aw). _l anr cxempt under B. & P.C.-21 -'?e I hcreby aflirm undcr penalty of perjury one dcclarations: _I have and will maintain a Certificatc of Consent to Self-lnsure for workers' comgrcnsation, as provided for by Section 3700 of the Labor Code, lor the Jrerformance of the work lbr which thc permil is issucd. _l havc and will maintain workers' conrpensation insurance, as required by Section 3700 of the Labor Code, for the performarrce of the work for which this permit is issued. My workers' compcns:rtion insurancc carricr ad plicy number are: Carrier: Policy Numtrcr: lixpires: _l ccrtity that in the pcrfbrmance of thc work for which this prmit is issucd, I shall not cmploy any pcrson in any manncr so as to becomc subjcct to thc workers' cornpensation laws of California. and agrcc that if I should becomc subject to thc workers' conrlrcnsation pmvisions of Section 3700 of the Labor Code, I shall, forthwith comply with those provisions. WARNING: Failure to sccure workers' comgrcnsation covcrage Ls unlawful. and shall suhject an employcr to criminal pcnahirx and civil lines up to one hundred thousand dollars ($100,UX), in addition to the of damages as provided for the Section 3076 of the l-abor C'ode, interest and attorney's fees. Iratc:2-2?:bL?t I I hercby aflirm undcr penalty of pcrjury that I am I)NCI,ARA'I'I0N under provision ol'Chapter 9 (cornmcncing with Section 7ffn) of l)ivision 3 of thc Busincss and Profcssions Codc. arxl my licensc is in full lirrce iurd etfcct. l,icensc Numbcr: I)ale: CONSTRT.'CTION I,ENDING AGT:NCY I hercby atfirnr under penalty of perjury that there is a construction lending agerrcy for the lrcrformarrce of the work for which this prmit is issucd (.Sec. .3097, Civ. C.). kndcr's Nantc: f [.cnder's Addrcss: APPLICANT DECLARATION I My affrnr under penalty of pcrjury one of the following declarations: Demolition Permits-Asbestos Notification Fetlcral Regulatiorrs (Title 40. Part6) -Required [rtter of Notifrcation _l certify that the federal regulations regarding asbestos renroval are not applicable to this project. reatl this application and state that the above information is corrcct. I agree to comply with all City and County representatives of this CitV3nd County to enter upon theand State l-aws relating to building constructiorta atxn'e mcntioned pnrpcrty lirr Applicanl or Agcnt I)rrnritcr nanle Purposcs. atd autlxrrize *r,, Z-21 -bZDt Rev. 08-07-2015 7Y, lt