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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.GOMMENTS OWNER IlUII,DER DELCARATION ! hercby allirm under ;vralty (,f psjury thal I m exempt from lhe ContracloE' Licqse Lnw for lhe fJllowiog reen (Ss.7031.5 Business md Profsion Code): Any ('ity or County rvhich require a pernit lo cons(rdcl. aho. inrprove. dmollsh or repair my slruclure, prior to ils issumce, alsc require the applicanl for such permit to lile a signed staternml that he or shc is lic@scd pEuilt to thc provisions ofthc Contractor's Liccnsed Law (Chapts 9. Commencing with Section 7000 ofDivision -3 ofthe Business md Professions Code) or that he ot she is exernpt lhsefrom af,d lhc basis for the allcged exmption. Any violation ofSection 7031.5 by any applicant lor a pennit subjects the applicant to a civil penahy ofnol morc thm l'ive hundred dollus ($500). l. as o$ no of the prolmy. or my ernpkrym wilh s ag6 6 lheir $le compemation. uill do lhc rvork ed lhe struc:lue 6 not intmclcrj oroffsedforsle(S@T04.l.BusinqsmdProlqsions('ode: TheConlractor'sLicenselaw'do6notapplyloanownsof lhcprcperly u'hobuildsorirnprovelhs@n.mdwhodo6suchrvorkhimselforhersclforthroughhisorhoorvnernployees, provided lhat such imprcvqnenls tre not inlmded or offoed for sale. If, howevs. thc building or inproveinml is sold within one )Ea' ofcomplaion. the Owner l]uildtr will have lhc budo ofproving thd he or she did not build or improve the prepoty for the pupos of sle). -1. m orvner of the propfly. eil e\chrsiveiy conlracting wilh licensed contracloE b coNtruct the projKt (Ss 7044. BustnN od Prcl'csionCodc:'lhcContractor'sLicenseLarvdosnotapplytomcwncrofpropqlywhobuildsorirnprovcsthcrcon. and who contracts for such prcjsts with I Contracb(s) licensed pursuilt to the Contractor's Liccnse Law). _l tun cxernpt unds Scction . U. & P.C. for this rcoon. l)nlc:()rrtrer WORKERS' COi!IPENSATION DECLARATION I hereby aflirm under poalty ofpojury one ofthe following deluations: I have ild will mainlain a Cmificate of Consmt lo Self-lmure for workm'compstrsation, 6 provided for by S{tion 3700 of lhc Labor Codc. for the pqfommce of thc work for which the pornit is issued. \(have and will mainrain work6s' compensalion imurance, 6 rcquired by Sation 3700 of thc Labor Code, for lhc psfomoce of 1[e work for uhich this pennit is issued. My workos' compcnsation insurmce cmiq md policy number oe: c*i,, 5+t,,/ rvk T1/\E1,L[aI/L{L poricyNurnber: BJUI^X-O I * QOAI Expires.- -.,1 cenify that in the pcrforntance of the work for which this p€rmit is issucd. I shall not ernphy any person in any manner so 6 to lEcome subjccl to lhc workqs' compensation laws of ('ali fomia. ard aurcc thal i f I should bccome subjsl to the workc'coilrp€nsalionprerisionsofSclion3T00oflheLatnrCode.lshall,forthsilhcomplyuilhthoseprovisions. WARNING: Failure kr *cure workers'comlmation coveraSe is unlawful. md shall subjel an onployo to oirninal penaltis md civil llnes up to one hundred thousmd dollas ($100.000), in addition to the cost ofcompemation.damages a provided for the Setion 1076 ofthc intqst and allomsy's f6. v tc)2D I hoeby aflirm under pmahy of psjury that I en licenssi unde provision of Chaptq 9 (cormencing wilh Strtion of lhe Busins md Profssions Code. ard mv licme is in full force md effst. of Divrsion ,t Liccnsc Nunrlrr: I hereby aflirrn undcr penalty ofper.jury that thee is a issued (Sec. -1097. Civ. C.). Lendo s Name: lending agency li)r thc polbrnrancc ofthe work ftir p6nit i\ Lmder's Addrs: - APPLICAN'T DECLARA'TION I hsdry afm unds psralty of psjury onc ofthe following dcclilations: Demolition Pmils-Asb6tos Notihcation Fedqal Regulations (Title 40. Pan6) Required Lcner of Notification _l ctrtif)'that thc federal regulatiom rcguding dbestos removal ile not applicable to this projed. I cfiify lhat I have rad this application ild state that lhe ah)ve infonnation is corcct. I agr€ to comply with all City and County ordinance ild Stale [Avs rclating to building coNtruction. ad hseby authorize reprqmtaliv6 of lhis City md County lo mts upon lhe amve mentioned p.openy for Applirtrnr or Agenl PermilNntrme(prinl): _ 0 Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloor/VenUl nsu lation Roof Sheathinq Shear Wall Framing lnsulation/Enerqy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif I FINAL k.lttl?.0 DfrT[,)C >*o-/ Certificate of Occupancy ll IU Notes, Remarks, Etc. I I qf tofz r ( oiltrictor I I