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BUILDING- !NSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNIIR BLill,l)l:lt t)llt,CARA'l'lON I hereby affirm under penalty ofperjury that I m excmpt fronr the Contraclo6' License L1w for the followinS rcasn (S6.70J1.5 llusincss and Profcssion Crldc): Any Cily or Couily which rcquires a fErmit lo conslrucl. nllcr, improve, dermlish or rcpair any stnrcture. prttr () ils issuance. allo reqnires the applicant tba such pcrmil to filc a signed slatemnt that lE or shc is liccn*d pursuant lo thc pmvisions o[ the Conlraclor's Liccnsed [,aw (Chapter 9. Cornrrcncing wilh Scction 70(n of l)ivision J ol the Busincss and PrclessionsCr)detorthutheor\heiserrmptthereliomandtltbasislbrthcallegedexempti(nr. AnyviolatiotrofSectionT03l.5byany dpplicrDr lbr a pcrmil subjects the npplicanr ro a civil pcoalt), of nor rmre thrtr five hundrcd dollars ($5(x)). _1. $ owner d,'lhc prortny, or my crnployecs wilh wagcs as thcir solc cornpcnsation, will do lhe work and thc structrtrc is not iileDded orofferedforsle(Sa.7044,BusinessandP()fessionsCodc:TheCoDltrrclor'sLicensekwdocsnolapplyloanowncrof the pft)fE(y wlx) tNilds or improws thcr<nl ud wlD d(Es such work himself or lErsell or through his or her own cmployecs. prolidcd lhal such imprevcrrents de mt intcnded or oll'crcd for slc. ll, howcvcr, thc building or ifprovcrrcnt is sH wilhin one yd ofconplerior, lhe Owner BuiIJcr will have thc burdcn ofpmving tlul lE or she did not build or inrprove thc pft)peny for lhc purlnse of sale). _1. as owner ofthe propeiy. am exclusively contraclinS with liccnsed conlrdck)r\ lo conslruct tlt pmject (Scc. 704,1. Busincss arxl [\ot*sitrlCode:ThcCortr!c(or'sLicenseLawdoesnotipplytoanowilcr{)fprope(ywhobuildsorimprovcslhercotr. rnd who contracts for such proiects with n Contraclor(s) liccnsc(! pursuanl lo thc Conlrac(tr'r Licensc Law). -lrmerem|rtunderseclion-.B,&P,C'lilrthrsreasrrn' woRKuRs' cot\rPB,NsA't IoN DT]CLARATt()N I hcrcby allirm undcr pcnilhy of perjury onc of thc lirllrwing dcclerations: _l have arul will nraintah a Ccrtiricale of Consent to Self:lnsure tirr workers' comperNillion, as prcviderl trrr bySccti()n 1700 of thc Lak)r Codc, for thc lrcrformmc of rhe work for which lhc pcrmil is i\sucd. _l have and will nrrintrin workers conrpeNalion insurance, as rcquired by (hc w(,rk ti)r which this pcrnlit is issucd. My workcrs' compensation insuruncc Scal()n 3700 of lhe tibor Codc, for thc pcrfotrurec of : crnicr and lxrlicy numbcr uc: Policy Numbcr: lixpires: _l cralify that in the lErli)rnuocc otlhc work for which this pcrnril is issucd. I shall not cnlpby any pcrson in any manner s as lo bcconE subject to thc workers' conTensation laws of Califonlia. and aSrcc thnt if I stnuld bccorrc suhjcct to thc worlcrs'conllEnsationprovisionsofSectiillST00oftheLaborCode,Ishall,lirnhwithcomplywilhtlpsprovision!. WARNING: Fdilure to sccurc workers'conrpensali()n coveragc is unlawful. and slull suhjccl an enrploycr to qiminul pcnaltiB and civil fines up to one hundrcd thousand dollars (Sl(X),uXD, in addition to the cost ofconrpcnsdtion. damges &s providcd for thc Sccli[ ]076 of rhe btx)r C(xle, intere$t and attorcy's fees. Datc:- UCI,NSE.CTINIBACIgE DECLARATION I hcrcby allirm undcr ttnally of pcrjury that I am licensld undcr provision ofChapts 9 (comrcncing with Sccthn 7ffx)) ofDivision ] of thc Busincss and Pmfcssions Codc, and my liccnsc is in full fore iuxl etfect. Liccnsc Numbcr: ll"'- CONS'TRT)CTION I,I:NI)INC AGENCY I hcehy aflirnr under lEnrlty of periury th0t there is s constructiur leudirg agerEy lor the perfomarEe oflhe work fi)r which this p€mil is issucd (Scc. 3097, Cir. C.). [.ndcr's Nnn]e: APPLICAiYT DECLARATI0N I hentryaffm undcr penalty ofperjury onc ofthe following d*hralions: Dcmolition Permils-Asbeltos Notification Federal ReSulations (Title 40, Pan6) -Requfed lf,tter of Notification _l ceniti lhar the fadcralrcgulntions rcSarding asbesbs removal are not applicnblc to this projert- _l ccnify rhal I have read this applicalion and stalc thnl lhe above irfomnlion is corecl. I aSrce to crmply wilh all City and County ordirrNes and Shtc kws rctrtirrg to buildirrg coNtructi(n\ ilrl hetehy aulhorize reprcseDtalives of this CIy atrd Coutrty to cntcr upon thc atx,vc mnlioncd pro1r(y for inspcction purF)ses. Appllcsnl or Agcnl Signutum: Dotc:_ l,cmlte nante (Drint): Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Subf loor/VenVl nsulation Roof Sheathinq WnOc wffi Shear Wall I l-r Framinq lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat JVasonry Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif I .l ^ r)- FINAL 5tu .Z uth^il 6-V ry Certificate of Occupancy I 'rl' Notes, Remarks, Etc. Rev.08-07-2015 [xndcr's AJ(lrcs\: -