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BUILDING- !NSPECTOR RECORD Rev. 08-07-201 5 SITE.WORK DATE ID/SIG COMMENTS ()wNI.tR IrUtt,t)!)t t)l).cARA'I t()N IhercbyaffrnrunderpcnaltyofpcriurythatIamexenrptfromtlreContracloN l-icenselnwforthcfollowingrcason(Sec.7031.5 Rusiness and Prdlcssion Code): Any City or Counly which requircs a lrcrmit lo construcl, altcr. improve. dcrnolish or rcpair any slnrcturc, prior to irs issuance. aho requires the applicant ti)r such pcrnril k) file a signed slatentsnt that Irc or sha is liccnsed pursuant lo rhc previsions o[ rhc Contractor's l,iccnsed law (Chapter 9. Comrnencing with Section 7UX) ol l)ivision 3 of thc Busincss and ProftssionsCode)orthatheorsheisetcmpltherelronraildtlEbasislirrthcallegedcxenrptiur. AnyviolationofSectionT03l.5byany applicrnt for n pennit sub.iects lhc rpplicaDl to x civil penolty ol-nol rnore lhan five hundred dollars ($5(X)). _1. as owncr ol'lhc profDny, or my ernployecs with wagcs as thcir sole compcnsrtion, will do (hc work and the structurc is mt irlerilql or ollered for slc (Sa.?(X4. Business and Pntfcsskts Codc: Thc Conlracor's Liccnr law dws not apply lo An owncr of thepmfEdy whohuildsorimprovestlEBnlar&lwlpdNssuchworkhinlselforhcrselforthroughhisorherownemployecs, provid!'d rhat silch irnpmvcmnts ee ml inlerded orollbed lbr Mle. ll, howcvcr, tho buildinS or improvemnt is sld within onc ycu ofconpletinr, llE Owtrr Builbr will havc the burdcn ofpovins llut hc or shc did mt buill or impovc thc prepeny for lhc purposc of sale). _1, as owner ofthc prcpcrty, am exclusivcly contractin8 with liccnsd conlraclors to conslruct thc prcject (Scc. 7(N4, Busincss aul PrrlissilrCode:TheConlracbr'sLicenseLawdoesnotapplybanowoerofpropenywhobuildsorimprovesthereon. and who contmcls for such projccts with a Coil@lo(s) liccnsd pursuant to the Coilractor's License kw). -IamexempIUndersection-.B.&P,C.l.rrrthisreason.Dsle:- W0RKI]RS' C0MP]]NSATT()N DECLARATIoN I hcrcby alli rm u nder penalr y of pcrjuly o nc of lhc Ib II('w ing dcc larar ions: _l havc and will nuintain a Ccnitlcate of Conscnt to SclElosure for workers' rnmpensat irn, as prcviderl for by Section J700 of the Labor Code, for the performrce ofrhe work for which rhe pcrmit i\ issued. I;have and will nraintain workcrs' compcNalion insurance, as rcquircd by Sccli()n 3700 oflhe llhor Code, fbr the pcrfomure-e of work t'()r which lhis lErmit is issucd. My workcrs' compcnsation rnsurancc cr[icr rmd lBlicy nunbcr $c: l,olicy 9 Lo _l ccf,ify lhat in thc perli)rmncc of the work for which this lrcrmil is issucd, I shill nol enrploy any pcrson in any mlnner so rs lo bccotrrc suhject to lhc workcrs' conrpensation laws ofcslifomia, and ngrce that if I should bccorN suhjcct to thc con)ply with thosworkers' conrpeDsrtion provisions of Section l70Oof thc tatxrr Codc, I shall, WARNING: Failorc to scurc workers'compcnsntion covcrrgc is unlawtirl,suhjcct xn k, crim!f,il| Fnaltics and civil llncs up to one hundred thousand dollars ($100.(X)q, Section 1076 ofthe htDr Cqle, intcre{ and arbrrey's fces. as provided for lhc u^,",7-lol'zo I hercby all'irm undcr penahy ofpcrjury that I am liccnrd I (cornrencing with Scction 70fi)) ol Division 3 of the Busincss and Protcrsions Code. aml my liccnsc is in flll fbrcc and Czq btLiceosc 1/\ CONSTRI'CTION I,I.:NDINC AGI.:NCY I heEby aflirm undcr Fnallyof perjury that thec Ls a con$nrdi(xr leriling agerry for the tErformree of thc work for which Ihis fEmit is issuetl (Scc. 3097. Civ. C.). [rnd!'r's Narne. kn<lcr's Addrcss: APPI,ICANT DECLARATION I hereby dffrm under penalty of perjury onc of thc following dmlarations: DenDlition Permits-Asbestos Norification Federal Regulations (Titlc 40. Pan6) -Required tf, lter of Nolification _l cenify lhilt thc ted€ral reSulaf ioDs regeding k) tlris pri)ic(1. \l ccrrify rhat I h{ve ren(l thi\ applicrtioo and rhe is corecl. I agr@ to conrply with nll Cily nnd Counly representalives of this Cily and Cotrnty to enter uF)n llEordiEnces and Slate Inws relariDg to ak)ve mcntionc(l propcny lbr Applicont or AgeBt l'rnnilcr nanr( and o z-14-ze Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Subf loor/VenVl nsulation ,l - -flRoof Sheathinq Zl2ol*)Dtf^1 tvL.-+>-l Shear Wall tl rt Framinq lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat lvlasonry Pool Fence T-Bar Handicap Req. Deputy Final Report Enqineer Final Report Flood Zone Certif I FINAL zlZqfut Dktfi1 x-+8"1 Certificate of Occupancy tt Noles, Remarks, Etc.,rr-o-I27t)Wl 01 xT7 - Dftm)sa#o7