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BUILDING- INSPECTOR RECORD SITE-WORK DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION \ I hcreby alfirm undcr pcnalty of pcrjury that I iun cxcmpt from thc Contractors' Liccnse law for thc following reason (Scc.7031.5 Busincss and Prof'cssion Codc): Any City or County which rcquircs a Jrcrmit to construct, altcr. improve, dcmolish or repair any structurc. prior to its issuance. also rcquircs thc applicant for such pcrmit to file a signcd stalemcnt that hc or shc is licenscd pursuant to thc provisions of thc Contractor's Licensed l-aw (Chaptcr 9, Comrncncing with Section 7000 of Division 3 of thc Busincss and Profcssions Code) or that he or she is cxempt thcrefrom and thc basis for thc allegcd cxcmption. Any violation of Section 7031 .5 by any applicant for a pcrmit subjcrts thc applicant to a civil pcnalty of not more than fivc hurdrcd dollars ($500). _1. as owncr of the propcrty, or my employecs with wages as thcir solc compensation. will do tlrc work and the stnrctue is rnt intcndcd or offcrcd for sale (Scc.7M4, Busincss and hofcssions Codc: Thc Contrac{or's Liccnsc law docs not apply to an owner of the proJrcrty who builds or improvcs thercrrn. and wlro docs such work himself or hcrsclf or through his or hcr own employecs. provided that such improvernents arc nol interxlcd or offcrcd for sah lf. howcwr, the building or inprovcnrent is sold wilhin one )rcar of complction. thc Owncr Buildcr will havc the burden of proving thBl hc or she did not build or improve thc propcrty for thc purynsc of salc). _1. as owncr of thc propcrty, am excfusivcly contracting with licenscd contractors lo construct thc projcct (Sec. 7W. Busirrcss and tlofession Code: Thc Contractor's Licensc Law docs not apply to an owner of propcrty who builds or improvcs thereon. and who contracts for such gnojects with a Contracto(s) Iiccnsed pursuant to thc Contractor's Liccnsc taw). -l am exctnpt undcr Sc'ction-, B. & P.C. for this rcason. Dale:--( )rr ncr. WORKERS' COMPE{SATION DT'CLARATION I hcrcby affirrn undcr pcrralty of pcrjury onc of the following declarations: _l have and will maintain a Certificate of Conscnt to Self-lnsure for workers' comgrcnsation, as gnovided for by Scction 3700 of thc l-abor Codc, for thc pcrformancc of the work for which the permit is issued. _l havc and will maintain workcrs' compensation insurarcc, as requircd by Scction 3700 of the labor Codc. for thc performarce of thc work for which this permit is issucd. My workcrs' compensation insurance carricr and plicy numbcr arc: STxr€ e-o^A f Policy \-t o-A -_q _2-\ _l ccrtify that in thc lrcrformancc of lhc work for which this permit is issued, I shall not employ any pcrson in any lrnnncr so as to bccomc subjcct to thc workcrs' compcnsation laws of California, and agrcc that if I should bcconr subject to thc workcrs' conrpensation provisions of Scction 3700 of thc l-abor Codc. I shall. forthwith corryly with thosc provisions. WARNING: Failurc to sccurc workcrs' comfrcnsation covcragc is unlawful, and shall suhjcct an cmploycr to criminal pcnaltics and civil fincs up to onc hundred thousand dollars ($100.0001. in addition to the cost gJ[rlmtrcnsation. danragcs as provided for the Section 3076 of the labor Code, intcrcst and attorncy's fees. .A. .A. ,/ I . Date:-1-]:fa-Z-O rppri."n,,(CO 4- LICENSED CONTRACTOR \.ECLARATION rprcr 9 (comnrncins wilh.so.J000) of Division 3I hcreby aftlrm under pcnalty of perjury that I am liccnscd undcr provision of Chaptcr 9 (comnrncing of the Busincss and hofessions Code, and my license is in full force and effect. Liccnsc C -L\9 (o tt -tq -rctI)ale: CONSTRUC'I'ION LI|NDING A(;UNCY I hercby affirm under Fnalty of [Erjury thar thcrc is a @trdruction brding agercy for the |rcrfol.tlDrcc of the work for whhh this fHmil is issued (Sec. 3097, Civ. C.). kndcr's Nam: [.endcr's Address: APPI ICANT DECI ARATION I hcrctry alilrnr undcr pnalty of prjury onc of thc following dcclarations: Dcmolition Pernrits-Asbestos Notification Fcdcral Regulations (Title 40. Part6) -Requircd l.cttcr of Notification _l certify that thc fedcral regulations regarding asbcstos rcnrovalarc not applicablc to this propct. _l ccrrify that I havc rcad this application and state that thc atnve infornration is corrcct. I agrcrc to comply with all City and County Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf Ioor/VenUl nsu latio n Roof Sheathinq Shear Wall Framing lnsulation/Enerqv Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputv Final Report Enqineer Final Report Flood Zone Certifa /Z./y-Oo rL C.z.rl/ F!NAL /2-y'{-?)/'2 (rCt 128 YUI Certificate of Occupancv Notes, Remarks, Etc. Rev. 08-07-201 5 thcordinanccs and State laws rclating to construction, and abovc rrrcntioncd propcrty for Applicant or Agenl I)ernrilec nanre H Hrl\J <L D"r.. l\-lq-zo