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BUILDING- INSPECTOR RECORD SITE-WORK DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION I hcreby affrm undcr lEnalty of pcrjury that I m excmpt t'mm lhe ContracloN' Liccns Law for the followirg M$n (Sc.7031.5 Busincss and Prcfcssion Code): Any City or Couily ehbh rcquircs a Jrcmit to constMt, alter, inqrrorc, &mlish or rqnir uy ^strctre. prkr to its issume, also rcquircs the spplicant for such pcrmit to fib a signcd stdemnt tlEr he or dE is lienrcd pursuat to the Fovisions of thc Contractor's Liccnmd law (Chapter 9, Comncing wilh Sction 700O of Division 3 of thc Busircss md PmfessionsCodc)orthBtheorshcisexcmptlhcrcfromandthcbasisfortlrcallcgedcxcmption, AnyviolalionofS@lion703l.5byany applicant for ! Itrmil subjEts thc applicrnt to I civilpcmltyof not mrc thm live hudrcd dollus ($500). , _1. as owncr of thc proprty, or my cmployccs with wagcs as thcir solc comJrcnsalion, will do thc work and thc structurc is rnl intendcd or offcrcd for salc (Sec.7044. Busincss and hofessions Code: Thc Contraclor's Liccnsc [-aw docs not apply to an owncr of thc propcrty who builds or funprovcs thcrcoru and who docs such work himself or hcrsclf or through his or hcr own employecs, providcd that such improverncnts are not intendod oroflcrcd for salc. lf, howcvcr. thc buikling or inprovcmcnt is sold wilhin onc year of comphtion, thc Owner Buiklcr will have thc burdcn of proving thal hc or shc did ncrt build or improve the propcrty for ttrc purprsc of salc). -1, as owncr of the profrcrty, am exclusively contracting with liccnscd conlractors to conslruct thc project (Scc. J$rH, Busincss and Profcssion Code: Thc Contractor's License Law does not apply to an owncr of propcrty who builds or improves thereon, and who contracts for such projccts with a Contractor(s) liccnscd pursuant to thc Contractor's Liccnse [:w). -IaIncxemptundcrScnction-.B.&P.C'forthisreason.Owner'wonxrwox DECLARATION I hercby affirm under pcnalty of pcrjury one of thc following doclarations: _l havc and will nraintain a Ccrtificate of Conscnt to Self-lnsure for workers' compcnsation. as gnovidcd for by Section 3700 of the Ixbor C-odc. for the performance of thc work for which the pcrmit is issucd. 6^ndwillmaintainworkcrs,compcnsationinsuralrce'asrcquircdbyScction3700ofthe[:borCode,forthcperformanccof thc work for which this permit is issucd. My workcrs' compensation insurance carrier and policy numbcr are: ioot--s',deCarrierNql Poricy Nu *r, WCL35 Z562 * Expires:O jt -O.t -Z _l ccrtify that in thc pcrformarcc of thc work for which this pennit is issued. I shall not employ any pcrson in any trulnner so as to beconrc subjcct to thc workcrs' compensation luws of California, nnd agrcc that if I should bcconre subjcct to thc workcrs' compcnsation provisions of Section 3700 of thc L:bor Codc. I shall, forthwith comply with those provisions. WARNING: Failurc to sccure workcrs' compcnsation covcrage is unlawful. and shall subjcct an enploycr to criminal pcnaltics and civil fines up to onc hundrcd thousund dollars ($100.000), in addition to thc cost o[ compcnsation, damages as provided for the Section 3076 of thc Labor Code, intcrcst and attorncy's fecs. I)alc:h -12->)r*non% LICENSED CONTRACTOR DF'CI,{RATION I am licenscd undcr provision of Chaptcr 9 (conrmcncing with Section 7000) of Division 3 rny liccnsc is in full force and cffcct. I hcreby affirm undcr pcnalty of ;rcrjury that I of thc Busincss and hofcssiorrs Code. arrd Liccnse Nurrtbcr:ag5o / o -o Y= W I hcrcby affirm undcr pcnslry of pcrjury thal Ihcrc is a @nsruclk n bnding agcrcy for the pcrforruce of lhc mrk for which this permit is is$cd (Se.3097, Civ. C.). kndcr's Nam: [.ender's Address: APPLICANT NT'CLARATION I lrocby affinrr undcr pcnalty of pcrjury onc o[ thc lirlkrwing dcclarations: Dc,n,,tiri"tf,fct6it*lsbcstos Nolificltion Fcdsal Regulations (Titlc 40. Pan6) !f,cquircd trttcr of Ndificdion -l ccrtify that thc fedcml rcgulations rcgading &sbcstos rcmval rc rct spplicsblc to this prcjcrct. -#r,n*l have rcad this rpplicstion ard state that thc above infortrution is orecl, I agrc to @mply with all city and County Gdiil'ares and Statc tiws Ehtirg to building constructiorl and hcreby autlrcrirc rcprescntatircs of this City and County to enls ulpn lhc atrovc nrcntioned property for inspcction Applicant or Agent Pernrilee nanre €t<r e o*".10. I -' 2O Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/Vent/l n s u I atio n Roof Sheathino Shear Wall Framinq lnsulatio nlEnergy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req. Deputy Final Report Enqineer Final Report Flood Zone Certif 1,. ---7, FINAL / z//b/zoz.fl ,dXL/// Certificate of Occu Notes, Remarks, Etc. Rev. 08-07-201 5 Darc: D