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BUILD!NG. !NSPECTOR RECORD SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcreby affirm undcr pcnalty of ficrjury that I am excnrpt from the Contractors' License [:w for the following rcason (Scc.7031.5 Business arxl Profession Code): Any City or County which rcquircs a pennit to construct, altcr. improve. dcmolish or rcJrair any structurc, prior to its issuancc. also rcquircs thc applicant for such permit to filc a signcd statenrcnt that hc or shc is liccnsed pursuant to the provisions of the Contractor's Licenscd [:w (Chaptcr 9. Comnrcncing with Sc.ction 7000 of Division 3 of thc Business and Profcssions Codc) or that hc or shc is cxcmpt thcrefrom and the basis for the allegcd exemption. Any violation of Scction 703 I .5 by any applicant for a pcrmit subjects thc applicant to a civil pcnalty of not morc than five hundred dollars ($5001. __1. as owncr of thc prof,cny, or my employees with wages as thcir solc comJrcnsation. willdcr thc work ard thc structurc is rnt intcndcd or ofl'cred lbr salc (Scr.7044. Business and Profcssions Codc: Thc Contractor's Liccnse law does not apply to an owner of thc profrcrty who builds or improvcs thcreon, and who docs such work himsclf or herself or through his or her own employees. providcd that such imlnovenrnls are not intendcd oroffcrod for salc. lf. howcrcr. thc buiUing or inprovcnrnt is rcld within onc )rcar of cornphtion, thc Owrcr Builder will havc thc burdcn of proving that hc or shc did not build or impmvc the propcrty for thc purJnsc of salc). -1. as owncr of thc proprty, am cxclusivcly contracting with licenscd contractors lo construct thc projcct (Sec. '1U4. Business and hofcssion Code: Thc Contractor's Liccnsc Law does not apply lo an owner of propcrty who builds or improvcs thercon, and who contracts for such projccts with a Contractor(s) liccnscd pursuant to the Contractor's Licensc kw). -lamcxelnptunderScction-.B.&P.C.forthisrcason.I)ale:( )rvltr.r' WOR KERS' COIVI PENSATION DECLARATION I hcrcby affirrn under pcnalty of pcrjury onc of thc following dcclarations: _l havc and will maintain a Certificate of Conscnt to Self-lnsurc for workcrs' compensalion, as povidcd for by Sectkln 3700 of the Labor Codc. for the pcrformancc of the work for which the pcrmit is issucd. _l have and will maintain workers' compcnsation insurancc. as required by Scction 3700 of thc [abor Code. for the grcrformance of the work for which this pcrmit is issued. My workers' compensation insurance carricr and policy numbcr are: Canicr: Policy _l ccrtify that in thc pcrforrnancc of the work for which this pcrrnit is issued. I shall not enrploy any person in any manncr so as lo bccorrc subjcct to thc workers'corrpcnsation laws of California. and agrce that if I should bcconrc subject to the workers' compcnsation provisions of Scction 3700 of thc [-atxlr Codc. I slrall. forthwith comply with thosc provisions. WARNING: Failurc to sccurc workcrs' compensation covcragc is unlawful, and shall subject an employer to criminal ;rcnaltics and civil fines up to one hundred thousand dollars ($100.000). in addition to lhc cost of conpcnsation. damnges as providcd for the o Scction Date:_ 3076 of thc l-:bor Code. interest I hcrcby aflirm undcr penalty of pcrjury that I am licenscd under provision of Chaptcr 9 (contnrencing with Scrtion 7m0) of Division -3 of thc Business and Professions Code. arxl my liccnse is in full lbrce and cffc'ct. Liccnse Nunrhcr: Dale:Corrlr:rctor.fn W I hcrcby affirm undcr Jrcnalty of Frjury lhat thcrc is a construction lcnding agcrcy for thc JErfornmcc of thc work for which this Frmit is issued (Sec. 3097. Civ. C.). lrndcr's Namc: [-ender's Address: APPLICANT DECI ARATION I trcrcby affirnr undcr pcnalty of perjury onc of thc following dcclarations: Delnolition Pcrmits-Asbcstos Notificalion Fedcral Rcgulations (Titlc 40, Part6) _Rcquircd [*ttcr of Notification -l ccrtify that thc fcdcral rcgulations regarding asbestos rcnroval arc fi)t applicable to this projcct. _l ceflify that I havc rcad this application and statc that thc atnvc information is corrcct. I agrcc to conply with all City and County ordinanccs and Statc [,rrws rclating to construction. and hercby authorizc rcprcsentativcs of this City and County to enlcr upn lhe abovc nrcntiorrcd propcrty for Applicant or Agent pr1". l(9 -?'.1 - 7020 Pernritee nanle l"l +D Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bf loor/VenVI nsu I atio n Roof Sheathino Shear Wall Framing Insulatio nlEnerqy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif. FINAL /Z-?-D {c-Cts JUeS Zr) Certificate of Occupancv Notes, Remarks, Etc. Rev. 08-07-2015 t ')L I----t