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SITE-WORK DATE ID/SIG. Set Bac ks Fo rm s/Steel/Holdowns Erection Pad s UFER Ground S LAB Fl oor }~.Lb Su bfloor/V ent/1 nsu lation v v Roof Sheathinq Shear W a ll Framinq lnsulatio n/Enerav D rywa ll Ext.lint. Lath Brow n Coat Ma sonry Pool Fence T-Bar Handica p Re q . Deputy Fin a l Repo rt Enq ineer Fin a l Rep ort Fl ood Zone Ce rtif. FI NAL Certificate of Occu pancy Not es, Rem a rks, Etc. BU I LDI N G-INSPECTOR RECORD COMMENTS OWNER B UILDER DELCARA TION I hereby affirm under penalty of perjury that I am e:'<.empl from the Contractors· Li cense Law for the following reason (Sec.7031.5 "" Business and Profession Code): Any City or County which requires a pennit to construct, alter, improve. demolish or repair any structw-e. prior to its issuance. also requires the applicant for such pennit to file a signed s tatement that he or she is licensed J!Ursuant to the provisions of the Contractor's Licensed Law (Chapter 9, Commencing with Section 7000 of Division 3 of the Business and Professions Code) or that he o r she is exempt therefrom and the basis for the alleged e.,cmption. Any violation of Section 7031.5 by any applicant for a pennit subjects the applicant to a civil pena lty of not more than five hundred dollars ($500). _1. as owner o f the propeny. or my employees with wages as their sole compensation. will do the work and the structure is not intended or offered for sale (Sec. 7044. Business and Professions Code: T he Contractor·s License L1w does not apply to an owner of the property who builds or improves thereon. and who does such work himself or herself or through his or her own employees. provided that such im provements 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 no t build or improve the property for the purpose of sale). _I, as owner of the property. am exclu sively contracting \\1th licensed contractors to construct the project (Sec. 7044. Business and Profession Code: T he Contractor"s License Law does not apply to an owner o f property who builds or improves thereon. and who contracts for such p rojects with a Contractor(s) licensed pursuant to the Contractor's License Law). _I am exempt under Sect ion ________ . 8. & P .C. for this reason. Da te: __________ Own cr:_~--~~--~-~------------- WOR KERS' COMPENSATION DECLARATION I h ereby affirm under penalty of pei j ury one of the following declarations: _I have and w ill maintain a Certificate of Consent to Self-Insure for workers· compensat ion. as provided for by Section 3700 o f the Labor Code. for the performance oft he work for which the permit is issued. _I h ave and w ill main~a· ,•o rkers· compensation insurance. as requ~'red b)'. ection 3700 of the Labor CF;(de, fi r he performance of the wor"')"t\th~his p nit is issued~1.:._ ,~o~k7\ compen~ ~uran c;gtrrier and po1?~1~ber are~ Carrier:--,/ r J 'CVJ,11'°~ Yc+t Hin _, --r Policy Number: Expires: __________ _ _I certify that in the performance of 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' compensation laws of California. and agree that if I should become subject to the workers' compensation provisions of Section 3700 o f the~a de, I shall. forthwith comply with those p rovisions. \VARNING: Failure to secure workers' compensation...,a erngef/ii.unlaw I. and 1a1l subject an c..>tnployer to criminal penalties and civil fines up to one hundred thousand doll~2?·000). in a • itio n th t of compensation. damages as provided for the Sectio\076 of the Labor Code. interest and attrey's fees. ~ __ Date: ,8-( ~-16 Applicii'iit: _ _,eU:__: __ '-:___--_ ~------- LI CENSED CONTRACTOR DECLARAT ION I hereby affirm under penally of perjury that I am licensed under provision of Chapter 9 (commencing with Section 7000) o f Division 3 or the Busin~ Professions Code. and my li cense 7.U,t. License Class , Li cense Nu~f:h (j ti~ L/ Date: J;;) ; f,::;--) h Contrn,:1:0;,,::=~=~-~·::::::::::::... ___________ _ CONST RUCTION LENDI NG AGENCY I hereby affirm un der penalty of pe1jury that there is a construction lending agency for the perfom1at1ce of the work for '\Vhic h 1his permit is issued (Sec. 3097. Civ. C.). Lender's Name: _________________________ _ Lender·s Address: _________________________ _ APPLICANT DEC LARATION I hereby affinn under penalty o f perjury one of the following dec larations: Demolition Permits-Asbestos Notification Federal Regulations (Title 40, Part6) _Required LellerofNotification _I certify that the federal regulations_r_eearding asbestos remo,,al are not applicable to this project. _I certify that~~have r th is appli catiognnd s le that the above infonnation is correct I agree to comply with all City and County ordinances and Stal ws relating to building ~st:cti?d hereby authorize representatives of this City and County 10 enter upon the above ment ioned . roperty ro, inspect ion p ~ (;;I rn-lb Applican t or Agent Signature:... ~ ,--~ --. ..-J f ________ _ ,r--:--=. _j_j1,,,a Permitee name (print):_~~),}_~~ -~--~~~'.SJV~ -"'Ad.,~~~~~-----------------•