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SITE-WORK DATE ID/SIG. Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Subfloor/Vent/lnsulation Roof Sheathino z.f gf 17 GtJ-e Shear Wall Framina lnsulation/Enerov Drywall Ext./lnt. Lath Brown Coat Masonrv Pool Fence T-Bar Handicao Rea. Deoutv Final Report Enoineer Final Reoort Flood Zone Certif. I I FINAL Certificate of Occuoancv Notes, Remarks , Etc. GUILDING-INSPECTOR RECORD COMMENTS I OWNER BUILDER D ELCARATION I he reby affirm under penalty of perjury that I run ex.empt from the Contractors· License Law fo r the following reason (Sec. 7031 .5 Business and Profession Code): Any Cit y or County which req uires a pennit to construct. alter. improve. demolish o r repair any stnictu.rc. prio r to it s issuance. also requires the a ppli cant for such pennit to file a signed statement that he o r she is licensed pursuant to t he provisi ons of the Contractor's Licensed Law (Chapter 9, Commencing with Sectio n 7000 of Division 3 of the Business and Professions Co de) or that he or she is exempt therefrom and the basis for lhe alleged exemplion. Any violation o f Section 703 I .5 by any applicant for a pennit subj ects the applic ant 10 a civil penalty o f n ot more than fi ve hundred dollars ($500). _I. as owner of the property. o r my employees with wages as their sole compensation. ,viii do the work and the structure is not intended or offered for sale (Sec. 7044. Business and Professions Code: The Contractor's License Law does no t apply to an owner of the propeny who builds o r impro ves thereon, and who docs such work himself or herse lf or through his o r her own employees. provided that such improvements are not intended or offered for sale. If. however. the building or improvement is sold within one year of completion. the Owner Builder will have the burden of proving that he or she did not build o r improve th e propct1y for the purpose o f sale}. _I. as ownerofthe property, am exclusive ly contracting w ith licensed contractors to construct t he project (Sec. 7044. Busi11css and Profession Code: T he Contractor's License Law docs no t apply to an o wner of pro perty who builds or improves the reon. and who contracts for such projects with a Co ntracto11s) licensed pursuant to th e Contractor's Li cense Law). _I run exempt under Sectio n ________ . B. & P.C. for this reason. Date: __________ Owner:. _______________________ _ WORKERS' COMPENSATION DECLARATION I he reby affirm under penalty of perjury one o f the fo llo wing declaralions: _I have and w ill maintain a Certificate of Co nsent to Self-Insure for workers · compensatio n , as provided fo r by Section 3700 of the Labor Code, ror the perfonnance of the wo rk for which the pennit is issued. _I have and wil l maintain wo rkers' co mpens ation insurance. as required by Section 3700 of1he Labor Code , for the perfonnance o f the work for which this pennit is issued. My workers' compensation insurance ca1Ti cr ru1d policy number arc: Carrier: ] r olic yNumber: ~ 9@0® Ex pires: --B'-----'--/ -----'--/1'---- _I certify that in the perfonnance o f the work for which this permit is issued. I shall not employ any person in any manner so as to become subject to the workers' com pensat ion laws of California, and agree that if I should become s ubj ect to the workers' compensation provisions of Section 3700 of the L1bor Code. I shall. forthwi th comply with those provisio ns. WARNl NG: Failure to secw-e workers' compensation coverage is un lawful. and shall subject an employer 10 criminal penalties and Section 3076 of the Labor Co de. inter~! and attorney'\ fees.:,-JI .# . civil fmcs up to one hundred thousand d o llru-s {$100.000).;uin add iL . o :zhc cost'lco pcnsation. damages as provided for Lh e Date: 12.-ZQ -/{; Applicanl:.,.e... v ~y.,cc:........:=c:::,.+--4=--=-...::.u;,A----=------ L l'"ENS ,~ O NTRA".T~ ( DEC LARATION_ / I hereby artirm under penalty of pe1jury that I am licensed under provision of Chapter 9 (commencing wit h Section 7000) o f Division 3 of the Business and Professions Code. and my license is in full force an d effect. License Class:: ______ --,------,--U~r .. / ~ .I Date /2 -w~ (<o Co nt rac~7 "7,' /J A I~ -~N"TR'"~NDIN22y I hereby affirm under penalty of perjury that there is a cons1ruction lend ing ag6ncy Jr· the pc..·-rformance of t he \vor k for which th is pennit is issued (Sec. 3097. Civ. C.). Lender's Name: _________________________ _ Lender's Address: _________________________ _ APPLICANT DECLARATION I hereby affinn under penalty of perjury one of the following declarations: Demo li tio n Permits-Asbestos Notirication Federal Regulatio ns (Title 40, Part6) _Required Leiter of Notification _I certify that the federal regulations regarding asbestos removal a.re not applica ble to this project. _I certify that I have read tlus a pphcat1on nnd state t hra?t)t the ~ above, information 1s cmn:ct I agree to co mply w11h all City and Coun ty ordmances and Stale Laws rcl~~\lng to 01_1stnnon, d eby au1horize r epresentalives ofth1s C 11y and County to e nter upon the above mentmned prope1ty for mspe ion purpo '·/_J .J Applicrml or Agent S ignntur q -~ I~ Date / 2 -2£}-( b Pcrn1itecname (11rinl)J-$ 1{/ ,{ C£,e:1Jb1;; r V o/4