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BUILDING- INSPECTOR REGORD SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hereby affirrn undcr pcnalty of perjury that I am excmpt from the Contractors' Licensc l-aw for thc following reason (Sec.7031.5 Business and Profession Codc): Any City or County which requires a pcrmit lo construct. alter. improve. dcmolish or rcpair any struclurc. prior to its issuancc, also rcquircs thc applicant for such pcrmit to filc a signcd statenrcnl that he or shc is liccnscd pursuant to thc povisions of the Contractor's Liccnscd hw (Chaptcr 9, Commencing with Scrction 7000 of Division 3 of the Busincss and Profcssions Code) or that hc or shc is exempt thcrcfrom and the basis for thc allegcd excmption. Any violation of Scction 7031\5 by any applicant lbr a pcrmit subjccts thc applicant to a civil penalty of not morc than five hundred dollars ($5001. _1. as owncr of the propcrty, or my employecs with wagcs as their solc comJrcnsati<ln, willdo the work and thc structure is not intcndcd or offcrcd for sale (Sec.7044. Busincss and Profcssions Codc: The Contraclor's Liccnse Law does not apply to an owncr of the propcrty who builds or improves lhcrcon. and who docs such work himsclf or hcrsclf <lr through his or her own cmployces, - providcd that such improvenrcnts are not intcndcd or offcrd fior sale. If, howcrar. the building or inprovcnrcnt is sold within one ),car of complctkrn. lhc Owncr Builder will havc thc burden of proving thal tE or shc did not build or improve thc propcrly for thc purynsc of salc). _1. as owncr of thc propcrty. am cxclusivcly contracting with liccnscd contractors lo conslruct thc projoct (Sec. 70tl4. Busirrcss and Prrofisskln Codc: Thc Contractor's Licensc Law docs not apply to an owncr of proJrcrty who builds or improvcs lhcreon. and who contracts ftrr such projects with a Contracto(s) licensed pursuant to lhe Conlraclor's License Law). -lamexcmptundcrScction-.B.&P.C.forthisreason.I1.,. ^. WORKERS' COM PET{SATION DECLARATION I hcrcby alfirm undcr pcnalty of perjury one of thc following declarations: _l havc and will maintain a Certificatc of Conscnt to Sclf-lnsure for workcrs'compensalion, Bs provided for bySectkrn 3700 of thc I-:bor Codc. for the perfornunce of thc work for which thc permit is issued. _l have and will maintain workers' comJrcnsation insurarrce. as required by Scction 3700 of the Labor Code, for the performance of thc work for which this pcrmit is issuccl. My workcrs' compcnsation insurance carricr and plicy number are: Rlr3u.t <- Mlwa l5 o t.u Policy _l ccrtily lhat in thc pcrformancc of thc work frrr which this pcrmit is I shall not cmploy any pcrson in any manncr so as lo bccomc subject workcrs' cornpcnsation to the workers'conrgrcnsation laws agrce that if I strould bcconr subjcct to thc provisions of Scction 370O of thc Code. I those provisions. WARNING: Failurc lo sccure workcrs' corr4rcnsation ts employer to criminal pcnaltics and civil lincs up lo onc hundrcd thousand Section 3076 of ttrf I-at$r C-odc, interest r)sre: *.-J+hzl 1-b dollars ($100.m0).thc cost of compensation. damagcs as providcd for the and att<lrrrcy's I hereby affirm undcr pcnalty of perjury that of thc Busincss and Professions Code. and LICENSED CONTRACTOR DECLARATION I arn liccnsed undcr provision of Chaptcr 9 (comnrcncing with Section 70m) of Division 3 my licensc is in full force and effcct. -qqN\L Liccnsc b Nurrthcr: tJ I hcrcby allirrn undcr pcnalty of pcrjury that issucd (Scc. 3097, Civ. C.). CONSTRUCTION LEI{DING {GENCY thcrc is a construction lcnding agency ltlr thc pcrformance of thc work for which thi*,rcrmit is Lrndcr's Namc: [.cndcr's Address:a APPI ICANT DECLARATION I hcrcby affrnn under pcnalty of pcrjury onc of thc following dcclarations: Dcrnolition Pcrrnits-Asbcstos Notification Fedcral Rcgulations (Titlc 40. Part6) _Rcqu ircd lrttcr of Notification asbcstos rcmovalarc not applicablc to this project. abovc nrcntioncd proJrcrty for Applicnnt or Agenl Pernritee nanre to lhal I Date:tl 'i7.1-D thc Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenU! nsu latio n Roof Sheathinq Shear Wall Framinq lnsulation/Enerov Drywall Ext./lnt. Lath Brown Coat Jt/asonrV Poo! Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif . FINAL lzl t1 l>o Dft+ryq Gertificate of Occupancv I Notes, Remarks, Etc. Rev. 08-07-201 5 , Owncr: Date: