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BUILDING- INSPECTOR RECORD SITE.WORK DATE ID/SIG COMMENTS OWNER BTJILDER DELCARATION I hcrcby atfirm undq pcnalty of pcrjury that I m excmpt from thc Contradom' Liccnse [:w for thc following reen (Ss.7031.5 Business and Prcfession Code): Any City or County which rcquircs a lrcmit to construct, altcr, improvc. dcmlish or rcIEia sy structurc, prior to its issume, also rcquires thc applicant for such lErmit to filc a signcd statcrent that he or shc is licensd pursumt to thc prcvisions of thc Contractor's Liccnscd hw (Chaptcr 9, Comncing with Sstion 7000 of Division 3 of the Busircss ild Prcfcssions Code) or that hc or she is exempt thcrefrom and thc basis for thc alleged cxcmption. Any violation of Scction 703 1.5 by ily applicant for a pcrmit subj@ts the applicant to a civil pemlty of not mrc the fivc hundrcd dolhs ($500). _1, as owner of thc property, or my ctnployees with wages as their sole compensation. will do thc work and the structure is not intcndcd or otfcrcd for sale (Scc.7M4, Business and Professions Code: Thc Contractor's Licensc l.aw docs not apply to an owner of thc propcrty who builds or improves thcrcon. and who does such work hirnself or herself or through his or her own employees, provided that such irnprovcrrrcnts are not intended or offered for sale. If, however. the building or irry)rovemcnt is sold within one ycar of completion. the Owner Builder will have the burden of proving that hc or she did not build or improve the proprty for thc purposc of salc). _1, as owncr of thc property, am exclusivcly contracting with liccnscd contractors lo construct the projcct (Sec. 7M4, Business and ftofcssion Codc: The Contractor's Licensc Law does not apply to an owner of progrerty who builds or improves thereon, and who contracts for such projccts with a Contmckrr(s) liccnsed pursuant to thc Contractor's License Law). _l amexempt under Date: B. & P.C. for this rcason. Owner: WORKEITS' CONII'ENSATION DIICLARA'IION I hcreby affilm under penalty of perjury one of the following declarations: __l have and will maintain a Certificatc of Consent to Sclf-lnsurc for workers' compcnsation, as provided for by Scction 3700 of the Labor Codc, fbr thc performancc of thc work for which thc pcrmit is issucd. L$ hru" ond 3700 of the Labor Code, for the pcrformance of the work for arxl policy number are: o Co oL-ol- ZoZPolicyoFO _l certify that in the performance of the work for which this permit is issued, I shall not cmploy any lrcrson in any rnnncr so as to bccome subject to the workers' compensation laws of Califomia, and agrec that if I should becorrc subject to the workcrs' compcnsation provisions of Scction 3700 of the Labor Code, I shall. forthwith comply with thosc provisions. WARNING: Failure to secure workers' compensation coverage is unlawful, and shall subjcct an employcr to crirninal penaltics and civil fines up to one hundred thousand dollars ($100.fin), in addition to the cost of compensation. damages as provided for the Section 3076 of the Labor Code, interest and attorney's fces.- u-2- zdzo I I hcrcby aftirrn undcr penalty of prjury that I am liccnscd undcr provision of Chapter 9 (conunencing with Scction 7000) of Division 3 of the Business and Professions Code, and my liccnsc is in full forcc and cffcct. o CLO o 2 I License Date: . ll-z- zo zd W I hcrcby affirm undcr lEnalty of lrcrjury that thcrc is a construction hnding agcncy for thc pcrformcc of the work for which this pcrmit is issucd (Sm. 3097. Civ. C.). Lender's Nanrc: [.cnder's Address: APPLICANT DECLARATION I hcrcby aftirm undcr pcnalty of perjury onc of the following dcclarations: Demolition Pcrmits-Asbcstos Notification Fedcral Rcgulations (Title 40, Part6) _Rcquircd lrtter of Notification -l ccrtify that the fcderal rcgulations rcguding asbcstos rcmval m not applicablc to this prciEI. Lts t ""rtify rnn I havc rcad this application erd statc that the above inforrEtion is conEct. I agrec to corply with all City and County ordinances and State lrws rclating io building construction, and hereby authorize rcpresentatiws ofthis City and County to cnts upon thc above mentioncd property for inspection 'WM Date: r (p\-zozoApplicant or Agent Permitee nanre Sipnature: D< P Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf Ioor/VenVl nsu latio n Roof Sheathinq Shear Wall Framinq lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat [\Iasonry Pool Fence T-Bar Handicap Req. Deputy Final Report Enqineer Final Report Flood Zone Certif FINAL lil lu,lu Dk*tr7 Certificate of Occupancv t Notes, Remarks, Etc. -> Rev. 08-07-201 5 (nrinr):K LUCIO e Ue L4s