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BUILDING- INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNI.IR llL,Il,l)Fllt I)lil.CARA'fION oI herehy affirm under penulty of per.iury that I :rnr exenlpl from the C'ontractors' l,icense Law for the followirtg reasotr (Set'.7031.5 ]lusincss and Prolbssitln Codc): Any City or County which rcquircs a grcrmit to construct, altcr. irnprovc. dcrnolish or rcpair any stntcture, prior to its issuance. alsrl requires the applicilnt ti)r such permit to lile a signed slatenEnl that lle or she is licensed pursuanl to th!. provisions of thc. Contractor's l,iccnsed Iaw (Chapter 9. Cornrncncing with .Section 7(XX) ol' l)ivision 3 ol'thc Busincss and Prof'cssions Crxle) or thal he or she is exenpt therelront and tlle basis lirr tlrc alleged cxenrption. Any violatiou of Seclion 7031 .-5 by any appliclnt for a lxrrnit subjects the applicant to .l civilpenaltyo[not tnore thun live hundred dollars ($StXt). _1. a.s owncr ol'thc propcrty, or tny cmployces with wages as thcir solc cornpcnsati()n, willdo the work and thc slructure is rnt irrtendetl or offcred frrr sale (Sec'.7(I14. Business nnd Professions Crxle: Tlrc Conlractor's License Law drrcs not apply to an owner of thc pnrperty wlxr builds or inrproves there<rq axl wlxr drrcs such urrrt hinrself or lrcrself or through his or her own enployees. pnlvidcd rhat such irnprovcmnts are rnt intended or olll.rcd for salc. ll. hou,evcr. thc building or impmvcrrrnt is sold within one ycar of conrlllerion, the Owr)er BuilJcr will lurve thc burden of proving tlurt lre or she did not build or improve the propcrty for the purpose of sale). _1. as owncr oIthe pr()pet'ty. am cxclusively contracting with licensed contractors to conslruct llre project (Scc. 70{4. Business huilds or impnrves llrereort.arxl llutlssirru Code: The Contractor's Licertse Law does ltot ap;rly to of property who and u,ho contracls lbr such pro.jc'cts rvith a Contraclor(s) liccnscd lhe Conraclor's License Law). -I tuntlcr It. & lr.c' ozo I hcrcby alfirm unclcr pcnalty of pcrjury onc of lhc t'olkrwing _l have and will maintain a Certiticate of Consent to Sell'-lnsure for workers' comJreruation, as prcvidecl for by Section 3700 of the Labor Code, [or thc pcrformance o[ thc work lbr which thc prmit is issued. _l lruve and will nraintain workers' conrpensation insurance. as rctluired by Section 3700 of llte Lahor (lode, for lhe perfornratrce of tlrc work tilr wlrich this pcrnrit is issuctl. My workcrs' c()ml)cnsiltion insuranr:c curricr arrl grlicy nunrhcr arc: Policy _l ccrrity that in thc ;rcrtilrnuncc o[tlrc work fbr which this pcrnrit is issucrl, I shall not cnrploy any pcrs()n in any manncr so as lo hccrlrr*- suhject to thc workcrs' conlpcnsatiorr laws of Calil'ornia, and agrcc that il' I should hccottrc subjcct to thc workers' conrlxnsation provisions of Section 3700 of the l-abxrr Ctxle, I conrply witlr tlrosc provisions. lVARNING: Fuilurc to sccurc workcrs' conlJrcnsulion covcragc is slrall subjcct an cnrpkrycr to crinrinul pnaltics antl civil firrcs up to one hundred thousand dollars ($l(X).(XX)). in o[ courpensatiorr. darnages as provided for the Seclion Corle, interest antl attorney's fees. 3 ZoZc) I hcrcby allirm undcr pcnalty of pcrjury that I arn liccn.scd undcr provision ol'Chaptcr 9 (cornmcncing with Scction 7fiX)) ol'l)ivision 3 of thc Busincss and Prolbssions Codc. and my liccnsc is in full lirrcc and cft'ect. Liccnse Class: License Numbcr: I 1,..,,. CONS'I'RT'C'TION I,I:NI)ING AGENCY I hercby allirnr urrler pelralty of per.iury tlut there is a corrstnrction leuding agency lirr tlre prfrrrmatrce of tlte work lirr which this Jrcrntit Ls issucd (Sec. 3097. Civ. C.). lrnder's Nanrc:I Lcnder's Atldress: APPI.ICA NT DECI,AR.{TION I hcrcby affrnr under Jrcnalty of perjury one of the followirtg declarations: f)enxrlit ion Permits-Asbcstos Notificat ion Fetleral Regu lat ions (Tit le 40, Part6) _Rctlu iretl [-etter of Notificat ion _l certify that the federal regulations regtrnling not applicahle to this pro.iect. _l ccrtify that I have reatl this application antl infornration is correct. I agree to comply with all City and County ordinances arrd State Laws relating to bujldirtg hereby authorize representatives of this City and lo enter ugrn tlr ulxrvc nrcntioncrl prop*rty tirr Applicant or Agcnt I'rrnritee nanle t- ,1 Z0zo Set Backs I Forms/Steel/Holdowns 7 IL L)bA,-+Pl< Erection Pads UFER Ground SLAB Floor Su bf Ioor/VenVl nsu lation Roof Sheathinq Shear Wall Framinq Insulation/Energy Drywall Ext./lnt. Lath Brown Coat JMasonry Pool Fence T-Bar Handicap Req Deputv Final Report Enqineer Final Report Flood Zone Certif rl , FINAL 7 LI 'Zo r>ffi 7 Certificate of Occupancy ,,\, Notes, Remarks, Etc..1 9,t/0/h7 -AW lA K €.\ Rev. 0B-07-2015 I Contructor: