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BUILDING. INSPECTOR RECORD SITE-WORK DATE ID/S!G.COMMENTS - OWNER BUILDER DELCARATION I hqeby affimr unds penalty of perjury that I m exempt 6om the Contractos' Licre law for the following r@n (Ss.7031.5 Businqs and Prcfsion Code): Any City or County which rcquirs a pemit to mnstrucl. alta. improrq &rnolish or rcpair any structue. [rk)r to its isumce. also rcquirs the applicant for such pcrinit to filc a signed statmmt lhat he of shc is licfficd pumuanl to the Eovisions of tlE Contractor's Licored larv (Chapter 9. Commencing with Sction 7000 of Division -1 of the Business and PrefessionsCode)orthatheorshcisexemptthcefromildthebasisforlhcallegedexmp(ion. AnyviolationofSethnTB3l.5byany applicant for a pemit subjsts the applicanl to a civil penalty ofnot rrcre thil five hundred dollus ($500). _ -1, as owner of the property. or my ernployees \\,ith wages as their sole compensation. will do the rvork and the structure is not intended or offered for sale (Sec.7044, Business and hofessions Code: The Contractor's License Law does not apply to an ou'ner of the propoly rvho builds or inrproves thereon. and rvho does such wod( himself or herself or through his or her own employees. provided that such improvanents are not intcnded or offered for sale. lf. hou'ever. the building or irnprovement is sold within one )rzr of conrpletion. the Orvner Builder will have the burden of proving that he or she did not build or improve the propoty for the purpose of sale). __ I. as owner of the propeay. am exclusively contracting rvith licensed contraclors to construct the project (Sec. 7044. Business and ltoftssion Code: The Contractor's License Larv does not apply to an owner of property who builds or improves thereon. and rvho contracts for such projects with a Contracto(s) licensed pursuant lo the Contractor's Liccnse Larv). -l arn exenrpt under Section- . B. & P.C. for this reason. l)ate:( )rv lrcr': \YORKERS' COI\IPENSATION DECLARATION I hereby affinn under penalty of perjury one of the follorving declarations: __l har,c and u'ill maintain a Certificate of Consent to Self-lnsure for rvorkers' compensation. as provided for by Section -1700 of the labor Code. ftrr the p€rfonnance of the rvork for which the pcrrnit is issued. _ _l have and rvill maintain rvorkers' compensation insurance. as required by Section -3700 of the Labor Code. for the performance of the work for which this permit is issued. My rvorkers' compensation insurance carrier and policy numbcr are: ,'*rrr, r _Policy Number: - -l cerrify that in the perfornrance of the work for rvhich this permit is issued. I shall not ernploy any person in any manner so as to becorne subject to the rvorkers' compensation larvs of California. and agree that if I should become subject to thc work€rs' cornpensation provisions of Section 3700 of the Labor Code. I shall. forthrvith comply rvith thosc provisions. WARNING: Failure to s€cure rvorkers' cornpensation coverage is unlarvful. and shall subject an onployer to ctiminal penalties and civil fines up to one hundred thousand dollars ($100.000). in addition to the cost of compensation. datnages as provided for the Section -1076 of the Labor ('ode, interest and attorncy's ^ DECI.ARATTON I hereby alTirm under penalty of perjury that I am licensed under provision of Chapter 9 (comrnencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Class:_ o"t.' f 0 -- Nurrrbcr: _ _ (lontractor:_ W I heby allirm undo pcnahy of perjury that thqe is a @nstruclion lording agocy for thc pafomoce of thc wrk for which this p6mit is issued (Se. 3097. Civ. C.). Lender's Adch'ess: APPLICANT DECLARATTON I hotby afiimundq penalty of pcrjury onc of lhc following d6l4ations: Demolition Patnits-Asbetos Notification Fcdsal Rcgulations (Titlc 40. Pan6) -Rcquired l*tto of Notification -l cfiiry that lhc tedqal rcgulatiom rcgilding Gb6tos rmoval sc rot applicable to this pmjet. -l cqrify that I hsvc rad this application ed statcthat the above infomstion is coEet. I agre to comply with all Cityand County ordimcc and Statc Laws rclaing to building consructioo ad haeby authoria rcprMtativ6 of this Cily md County to ots upon thc above mentioned property for I Applicnnl or Agenl Pernritee name (print): ,rr", (6-7/ -/? Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloor/VenU! n su Iation Roof Sheathing Shear Wall Framing lnsu lation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif FINAL /2704 lo (2;d7;q2 ry-tl Certificate of Occupancy Notes, Remarks, Etc. ,^1-fl/-\ I Lender's Name: a