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SITE.WORK DATE ID/SIG.COMMENTS OWNER BtllLl)ER l)l,ll,CARA'rlON <br />I hereby affirnr under penalty of perjury that I am exenlpt fronr lhc Cbntraclors Licensc ljw for lhe following rcason (Sec.703 1.5 <br />tlusiness ard Profcssion Codc): Any City or County which rcquircs a Jrrrnit k) consttuct, aller, improve, dcmlish ot repair any <br />stnrcture. prior k) its issuance. llso rcquircs lhc applicrtrt tbr such pcmrit b filc a siSmd slatcrcnl lhal IE or shc is licensd pursuant ' <br />ro rhc provisions of thc Conlraclor's l,ic.nscd lrw (Chsptcr 9, Comrnencing with Section 7(Xn ol l)ivision 3 ol the Business and <br />ProfessionsCode)ortharlporshei\erempltherekomandthebasistirrtheallegedexemption. AnyviolationofSectionT03l.5byany <br />dpplicinrforrpemitsub.,ectsthc npplicantloacivilpcniltyofnotrmrethxnllvehundreddollars($5(D). <br />\. as owncr ol thc propny. or my employces with wages as lhcir solc cornpcnsation, witl do lhe work and thc structure is not <br />iueuler.l or offered for sle (Se.7(X4, Businesr snd PNfe$sions Cq.ler The Contrnclor's Lican* hw docs not apply to an owncr of <br />rhe frNFEfly wl$ builds or irprows themL :ud who des such work himsell or lErself or through his or her owtr employees, <br />providcd that such improvclren(s trc mt intcnded or ollbrcd for salc. ll. howcvcr, thc building or ifiprovcrrcnl is $ld wilhio one ,re <br />ofconrpbtiur. the Owrrr Buikler will luve the burden ofpmving tlun he or shc did ux builil or impnrve thc prcpeny ft)r tlE purfns of <br />sab). <br />_1, os owner ofthe pfi)peny, nnr exclusively contrdctirrg wilh lioensed conlr.clors lo conslrocl the project {Sec. 7044, Business <br />alxl Pn)llssi(nlCode:TheContractor'sLicensel,awdoesnotapplyto!nownerofpropcrtywhobuildsorinpr()veslhercoil. <br />ind who conlracls li)r sltch proiccts with a Contractor(s) liccnscd pursuant to tlR! Conlractor's Liacnsc kw). <br />I xnrcxrntr)I under B. & P.C. li,r this rca\oo. <br />WORKI,IRS' ( Ol\l PENSA'l'ION <br />t)ECt,ARATtON <br />I hcrcby nllirm undcr pcnahy oI pcrjury onc of lhc lbllowing dcclarnli(,trs: <br />_l h{ve ild will nniilain a Ce(ilicate of Consenl to SclLlilsurc for worliers' conrpensotion, as pnrvirled for by Section 1700 of thc <br />Lalnr Codc, for lhe pcrlbrmancc ol thc work lor which thc pcrmil is i\sued. <br />_l have aril will mairnai[ workeN comp€nsation insurance, as rc(|uircd by Sectiur 3700 of lhe hbor Code, for the pcrfornuNe of <br />thc work li)r which lhis pcrnrit is issued. My workcrs' compcnsati()n insurmcc curicr an{l |x)licy numbcr ue: <br />I'olicy <br />_l ccnily lhar in rhc lrrtbrnlancc r)f lhc wrrk for which this pcrnlil is issucd, I shall not cnrploy uny Nrson in any mrnn.r <br />so astottconrcsuhjccttolheworkcrs'conrpcilsationhwsol-Calilornia.andrsrccthatiflshouldbccormsuhjcctlothe <br />workcrs'conqrcnsationlrovisionsofSection3T00oftheLilborCode,lshall,fonhwithconplywilhtlD*provisions. <br />WARNING: Failurc tr sccurc wokcrs'cr)mpcnsati()n covcrage is unlawful, und shall suhjcct an cnlploycr k) ctminil lrnaltics Md <br />civil fines up ro onc hundrcd lhousaild dollus (Slu),{xx)). in addilion lo rhe cost o[conlpcnsalion. daftrgcs as providcd for lhc <br />Section 3076 ofthe Liltx,r C(xle, iri€rest and alhmey's fces. <br />I)I]CLARATIoN <br />undcr provisir)n ol Chapk:r 9 (cornrncncing withI hcrcby allifln undcr pcnally ol p!rjury lhal I <br />ol rhe Busincsr nnd Pnrtcssions Codc. iwl r <br />7(X[) ol'l)i\ision 3 <br />liccnsc is in full firrcc iuxl elfcct <br />Liccnsc Nurnh+r: <br />Contractor: <br />CONSTRTICTION I,I]NI)INC AG}:NCY <br />I heRby allirnl under Fnaltyof perjury that there is a cotrstnrclion lcrding agency li)r the perfomrce of the work for which thi$ lEmit is <br />issucd (Sec..1097, Civ. C.). <br />l.cndcr's Nrnrc. <br />l,cnrlcr's AtltLcss: <br />APPI,ICAT{T DECLARATION <br />I herrby atrml under pcnalty of pcrjury onc of thc following delalntions: <br />Dcmlition Pcrmils-Asbestos Notification Fcdcral ReSulations (Titl.40, Pdl6) <br />_Requted lrtrer of No(i6€lion <br />_[ ccf,ify lhat ttrc federalrcgulatioru rcguding ashe$k)s rcmvalsre not applicablc to this prcjret. <br />-kcnify lhal I have rarl this applicarion arxl stalc thal thc above infonnalion is corcct. I s8r@ to $mply with all City and County <br />onlifunces and State Laws rchting lo building constructiou, and herehyauthorize rcprcsentativcs ofthis City aild Countyto cntcr upon thc <br />atxrvc mcntiruerl propcf,y l(,r inspccli()n puryx)scs. <br />Appli(ant or Agcnt <br />I'rrnrilcr natrrc <br />,.4 **, =/s/az <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVl nsu lation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Eneroy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />fvlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />I \ll <br />FINAL 7U,U WJdVni dt <br />Certilicate of Occupancy <br />Notes, Remarks, Etc. <br />BUILDING- INSPECTOR RECORD <br />Hev.0B-07-2015