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BUILDING-INSPECTOR RECORD r--------------------,--------.--------.------------------..-------------------------------------------c: OWNER BUI LD ER DELCARATI ON ]7 SITE-WORK DATE ID/SIG. COMMENTS Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Subfloor/Vent/lnsulation Roof Sheathinq Shear Wall Framing lnsulation/Enerqy Drvwall Ext.lint. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif. /".,..... FINAL Certificate of Occupancy V \....._..., Notes, Remarks , Etc. I hereby affirm under penalty of perjury that l run exempt fro m the Contractors' License Law for the fo llowin g reaso n (Scc.7031.S Business and Pro fession Code): Any Cit y or County which requires a pcnni1 to construct, alter. improve. demolish or repair any • stru cture. prior to its issuance, also req uires th e appli cant for such pennit to fi le a signed statement th at he or she is licensed pursuint to the provis ions o f the Contractor 's Licensed Law (Chapter 9. Commencin g with S ection 7000 of Division 3 o f the Busin ess and• • Profe ssions Code) or that he or she is e xempt there fro m and th e basis for the alleged exemption. Any v iolation of S ection 703 1.5 by any appl icant fo r a pcnnit su bjects th e ap plic an t to a civil penalty of not more than five hundred dollars ($500). _I, as owner o f the pro perty, or my employees with wages as their sole compensation. will do the work an d the stru cture is not intended or offered for sale (Sec. 7044, Bus iness and Professions Code: The Contractor"s License Law does not apply to an owner of the property who builds or improves thereon. and who does such work hi mself or hersel f or through his or her own employees. provided t hat such improvements are not intended or offered for sa le. If. however. the bui lding or improvement is sold within one year of complet ion. the Owner Builder will have the burden of proving that he or she did no t buil d or improve the property for th e purpose of sale). _I. as owner o f the property. am exclus ive ly contracting wit h li censed contractors to construct the project (Sec. 704 4. Business and Pro ression Code : The Co nt ractor's License Law does not apply to an owner of property who buil ds or imp roves t hereon. and who contracts for such project s with a Contractor(s) li censed pursuant to the Contractor 's License Law). _I am exempt under Section ________ . B. & P.C. for this r easo n. Dale: __________ Owner: _______________________ _ WORKERS' COMPENSA TION D ECLARATION I hereby affirm un der penalty o f perjury one of the fo llowing declarations: _I have and will maintain a Cert ificat e o f Conse nt to SeJf.Jnsure for workers· compensatio n. as pr0\1ided fo r by Sec tion 3700 of the Labo r Code, for th e perfonnance o f the work for wh ich the pennit is issued. _I ha ve and will main ta in workers· co mpensatio n insu rance, as required by Section 3700 of th e Labor Code. for the perfommncc of th e work for which this pennit is issued. My workers· compensation insurance carrier and policy number are: Carri er:' ~\~~l..<::>6'1 ::I::r,.J~~CJ'i'. Policy Num ber .,.3\.Nc:_'3 S:~ si-ci -Ex pi rcs:__G• 3 (:)~\ 7_ _l cert ify that in the perfomm nc e 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 ofCalifom~ia. and agree that ifl sh~ould become subject the workers' co mpen sation provisions of Section 3700 of the LaOOr Code. I sha ll. forth with comply with those prov· ons. WARNING: Failure to secure workers' co mpensatio n coverage is unlawful an d shall subj ect an emplo ' to criminal penalties and civil fin es up to one hundred thousand dollars {$100,000),~in II n to the c of co ensnti o amages as provided for the Section 3076 of the Labor Code. interest and attot· ·s fees. __,, Date: -\2 • \ :S---) {._, Appl ant: _.,..._ ___ ~ • LICENQl;:ll CONTRACTOR DECLARATION I hereby affi rm under pe nal ty of perjury that I am licensed und er provision of Chapter 9 (commencing with Sectio n 7000) of Division 3 o f the Business and Professions Code. an d my license is in full force and e ffect. I , License Class: ~ /License N umber: 99 L []79 / Onie: -7-3)~\& Contrn\.J ./7 ./',:;--//A\..\ ,..r,.~ x__-/r " ?-eo....,~~vO\I('-' CONSTRUCTI-ON L END I NG AGENCY l hereby affirm un der pen alty of pe1jury that there is a constructio n lendi ng agency fo r the perfonuance of the work for which this pennit is is sued (Sec. 3097, Civ. C.). Lender·s Name: _________________________ _ Lender's Address: _________________________ _ A PPLICANT DEC LARATION I haeby affinn un der penalty o f perj ury one of th e fo ll owing declarations: Dem ol ition Permits.Asbestos Notificatio n Federal Regulat ions (T itle 40. Part6) _Requir ed LctterofNotificat ion _I certify that the federal regulations regardin g asbestos removal are not applicable to 1s project. _I certify that I have read t'.t.rlus apphc:allon and~stat ve mfonnation is rrect I agree to comply with all City and County ordma nces an d State Laws relating t butl~~m, truct1on . a auth representati ves ofth1s Cny and Count y to enter upon the above mentio ned pro peit y for io n p s 1----------------------------------------------------~ App li cant or Agent Signatm -Da te .. \2-,s--1 k Permitce 1rnn1c (print ): ,J,-/ \?....o'-,J '£_ \J ~_,~...,iS:')_,._,_:\~'\,"-"N,R_,,_....,,.._ ________ _