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BUILDING- INSPECTOR RECORD SITE.WORK DATE ID/SIG COMMENTS OWNER BT'ILDER DELCARATION t hcrcby affirm under ,rcnalty of pcrjury thal I u crctrpt ftom thc Contraclom' Licensc hw for Ihe following mmn tSec.zBt.l Busincss ard Profcssion Code): Any City or County which rcquircs a ;rcmrit to conslml. allcl improvc, dcmolish or rcJuir ut! strclurc, lrirr to its issurec. alm rcquircs the applicant for such lEmit to Iilc I signcd stalcmnt lhat he or shc is liccnrcd pusuilt to thc Fovisions of thc Contractor's Licen*d trw (Chaptcr 9. Comrcrcing with Sction 70fl) of Division 3 of thc Busiress md PrcfcssionsCodc)orthathcorsheiscxcnptthdefromardthcbssisfortlEallcgcdcxcmption. AnyviolationofstrtionT03l,5byanl applicsnt for o pcrmit sbjsts thc applicet to s civil pcnalty of nol mrc thu fivc hundrcd dollus ($500). __1. as owrrcr of thc prof,crty. or my employccs with wagcs as thcir solc conlpcnsation, willdo thc work and the stnrclure ls mt intcndcC or offcrcd for sale (Sec.70l4. Business and Profcssions Codc: The Contraclor's Liccnsc l-aw docs not apply lo an owncr of thc pmpcrty who builds or inrproves thcrcon. and who dcrcs such work himself or hcrsclf or through his or hcr own employces. providc-d that such imp,r<lvcnrcnts arc not interxlod oroffcrcd for salc. If. howcver. thc building or irprovcnrnt is sold within onc )rcar of cornpbtion. thc Owrrcr Builder will havc thc burdcn of proving that hc or she did not build or improve thc propcrty for the purpsc of salc). _1, as owncr of the proFrcrty. arn exclusively contracting with liccnscd contractors to construct the prolcrt (Scc. 7W, Busincss and hofcssion Cotle: Thc Contractor's Liccnsc Law does not epply to an owncr of propcrty who builds or improves thereon. and who contracts for such projccts with a Contractor(s) liccnsed pursuant to the Contraclor's Licensc [aw). ---l am excmpt undcr Scction--, B. & P.C. for lhis reason. I)ale:Owner:__ WORKER.S' COM PEtr{SATION DECLARATION I hereby aft'irnr undcr pcnalty of pcrjury one of thc following dcclarations: __l havc urd will maintain a Certificatc of Conscnt to Self-lnsure fbr workers' comgrcnsation, as provided tbr by Scction 3700 of thc l-abor Codc, for thc pcrfornrance of thc work for which the pcrmit is issued. y'l nur" and will maintain workers' compensation insurance, as required by Section 3700 of the t-abor C-ode, for the performarrce of thc work for which this permit is i.ssuod. My workers' qompensation insurarrce carrier and gnlicy numbcr arc: ,*,*,, ?J,.i € f-r r-,t l Policy _l certify that in thc Jrcrformancc of the work for which this pcrrnit is issued. I shall not employ any pcrson in any tnanncr so as to bccomc subjcct to thc workers' compcnsation laws of California. and agrec that if I should bcconrc subject to tlre workcrs' compcnsation provisions of Section 3700 of thc l-:bor Codc, I shall. forthwith cnmply with thosc provisions. WARNING: Failurc to sccurc workers' comgrcnsation covcragc is unlawful. and shall subjcct an cntployer to criminal pcnaltics and civil tincs up to onc hundred thousard dollars ($100.0m), in addition to thc cost of compcnsation, danrages as providcd for thc Section 3076 of thc labor Codc, interest and attorncy's fces. D,t", ttf tb/Lo I,ICENSI'D C(TN'I'RACTOR DI.'CLARA'I'ION I hercby affirm undcr penalty of pcr.yury that I am liccnsed undcr provision of Chaptcr 9 (comnrncing with Scrction 7Un) of Division 3 of the Business and hofcssions Codc, and my license is in full force atrd effect. Licensc Nunrbcr:to{tq&1 I)ate:tt/tL., /, t)fic4w W I ltrcby affm urdcr Jrnalty of lrrjury thar th@ is a construction hnding agcrcy for thc psformnce of the uork for which this Jsmit is issued (Scc. 3097, Civ. C.). Lcrtdcr's Naltrc: Lrndcr's Addrcss: APPLICANT DECI ARATION I hoeby aftirm undcr ;rcnalty of prjury one of thc following dcclarations: Demolition Pcrmits-Asbcstos Notification Fedcral Rcgulations (Title 40. Part6) _Rcquircd lrttcr of Notilication t --l ccrtily that thc fcdcral regulations rcgarding asbcstos rcmovalarc not applicablc to this projcrct. l)ermilce nanle Set Backs Fo rrn s/Stee l/Ho ldowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenUl nsu latio n Roof Sheathing Shear Wall Framing lnsulation/Enerqy Drywall Ext./lnt. Lath Brown Coat Jtlasonry Pool Fence T-Bar Handicap Req Deputv Final Report Enqineer Final Report Flood Zone Certif . FINAL lLl'll7r/>k*81 Certificate of Occupancv l Notes, Remarks, Etc. Rev. 08-07 -201 5 a (/ I and state lhat alxrvc mcntioned properly frrr ittspcction purposes. rt pplir'rutl or r\gcttl