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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS Owner-Builder Dccltu6rion IherebyaffrrnrunderpenaltyofperjurythatIamexemptformtheConlractors LicenseLawforthefollowingreason(sec703L5Busincss .nd Profcssion Codc): Any ('ily or Counl), which requires a perrnil lo conslrucl. aher. improve, dcmolish or rclair any slruclure. prior ro its issuance,alsorequircthcapplicantforsuchpcrmiltofileasigncdslalcmenl thf,theorsheislicenscd pursuantlotheprovisionsofthc Contraclor's Licensed Law (Chapler I, Conlnrencing wilh Seclion 7000 of Division I of the Business ind Profo.ons Code) or lhat he or shc is cxcmpl thdefrom and lhe basis for the allcged cxemplion .Any violation ofSection 70-1L5 by any applicant f&l a pennit subjects rhe applicanl 1o a civil pcnalty ofnol rnorc lhan llve hundred dollam ($500). l. as owner oIlhc properly. or my employces with wages as lheir solc cornpensation. will do the work snd the structure is nol inlended or offered for sale ( Sec 7044. Busrness and Professlons Code The ContrBctor's l-icense Law does nol applv to an owner oflhe propeny who builds or irnproves lhercon. and who docs such work himsclfor herselfor through his or her owf, employees. provided lhat such intprovcmenls are nol inl.nded or offercd for salc. If. howe!cr. thc building or irnprovemenl is sold wilhin one ycar ofconlplction. lhe ()wner-Builder rvill have lhc burdcn of proving lhat he or she nol build or improve l(]r the purposc ofsale)- -. l. as owner oflhc property. am cxclusively contracting with licensed contractors k) construct thc prdecl ( Sec. 7044. Business and I'rcfessi()n Code The Contractor's [-icense hw does not apply to an owner of propeny who builds or inrproves lhereon . and who contrlcts for such p.o.lds with a Contr.clor(s) licenscd pursuanl to the Conlrador's Licensc [rw.) _l am cxcmpt undcr Sslion _.8. & P.C. for this rccon. Datc: Owns: WORKf, RS COMPf, NSATION I'ECLARATION I herehy aflirn under penalty ofpcrjury one oflhe following declaratioils: I have and will maintain a Cenilicatc ofConsent lo Self-lnsure for workers' compensatron, as provided for by Secrion 37oo ofthe lrbor (bde. for lhc pcrforrnancc oflhc work for which thc pennit is issued. I have and wrll marnlain workers @mpenslion insurance. as required work for whrch thrs permI rs rssued My workers conrpensalron rnsurancc canier S",{-tfDot\4,21^rs by Section 1700 ofthe labor Code, for the perforroncc ofthc canicr and policy numbr arc:,,_L41 ._ rori.yH,,u",,[dl?lrtf - /t( - -Expircs:(This scction nced not be c6rnplcled iflhe pcrrnit is fiir One hundred dollars {$100} or lcss) I ceni[y lhnt in thc performancc oflhe work for rvhich lhis is I shall not any person in any rnanner so as to to lhe workers' compenstron laws ofca rfl subject to the workers conrpensalion trare, .h provisions of Sectionlrlr[1700 oflhc l-ahor ('odc. I provisions.. wARNINC ,railure to secure workers compensalion coverage rs unlawful. and shall sub_lect an employer to cdminal pensllies and civil fines up to onc hundred thousand dollars ($100.000).in addilion to lhe cost ofcompensalion. darnaScs &s providcd for lhe Scclion .1076 of the Labor Code. rnler6t and allorney's fees LICENSED CONTRACTORS DECLARATION I hereby amnn under penalty of pcrjury that I am licensed under provision of ('h6pter 9 (cornrnencing with Section 7000) of I)ivision -3 of lhe Business and Profcssions Codc. and my license is in full force and effect- Licensc Class: l)^tc: _.__-_ ourllrq [,icense I w*( onlraclorl CONSTRT'CTION LENDING AGENCY I hcrcby aflirm undcr pcnally ofpcrjury that thcrc is a coNtruction lending agcncy for thc pcrfomance ofthe work for which this permit is issucd (Ss. 3097. Civ. C.). Lender's Name l.cnder's Addrcss: APPLICAN'I"S DECLARA"TION Demolition Permits-AstEslos Notification Federal Resulations ('l itle 40. Pan 6) _ Required t-eller of Notification I cenify thal the federal regulalions regardinU asbestos reilroval are nol applicablc to this project. I ceniry that I have rcad lhis ion and slatc thal lhe ahove information is conect. I agree lo comply wilh all Cily and County ordinances and State [nws authorizc represenl8livcs of this G-o.r., sbove ,nentioned property for Applicant or agcnt sig.: Pcmitlr namc (prinl): Io conslruction.u,id: Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Subfloor/VenUlnsul Roof Sheathing Shear Wall Framing lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif ,fl FINAL ld/nz/E -lM/r ,) Certificate of Occupancy '/<w Notes, Remarks, Etc