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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.}. COMMENTS OWNER BUILDBR DELCARATION I hcrcby affirm undcr pcnalty of prjury that I am cxempl from thc Contractors' Licensc law for lhc following reason (Scc.7031.5 Busincss aml Profcssion Code): Any City or County which requircs a pcrmit to construct. allcr. improvc. demolish or reJxrir any structurc. prior to its issuance, also rcquircs thc applicant for such Jrcrmit to filc a signcd slatcmcnt that hc or she is liccnsed pursuant to thc provisions of thc Contractor's Licenscd l-aw (Chapter 9. Conrmcncing with Scrction 7000 of Division 3 of thc Busincss and Prol'cssions Codc) or that he or she is excurpt thcrcfrom and thc basis for the allcged cxemption. Any violation of Scction 7031 .5 by any applicanl for a pcrmit subjects thc applicant lo a civil penalty of not morc thm fivc hundrcd dollars ($5001. _1. as owrrcr of thc propcrty. or my cmployces with wages as their sole comgrcnsation. will do the work and thc structue is not intendcd or olTcred for sale (Scr.7044, Busincss and Profcssions Code: Thc Contractor's Liccnse law docs not apply to an owner of the propcrty who builds or funprovcs tlpreon. and who drrcs such work hirnsclf or hcrsclf or lhrough his or hcr own employees, providcd that such imJnovcrncnts are not intendcd or offercd for sale. If. howcrrcr, thc building or inprovcnnnt is sold within one )aar of complction thc Owncr Buildcr will have thc burdcn of proving that tE or she did not build or improvc tlrc property for tlrc purynsc of salc). _1. as owncr of thc propcrty. arn exclusivcly contracting with licen:;cd contractors to construct thc projcrct (Sec. 7W, Busittcss and Profession Code: Thc Contractor's Liccnse Law does not apply to an owner of propcrty who builds or inrproves thercon. and who contracts for such projccts with a Grntractor(s) licensed pursuant to thc Contractor's Liccnse [aw). -l am excnrpt undcr Section-. B. & P.C. for Date: f :+-?p?D, I hcreby alTirrrr undcr pcnalty of perjury onc of thc _l havc and will maintain a Ccrtificatc of Conscnt to Sclf-lnsurc for workers'compcnsation. as providcd for by Scction 37fi) of thc labor Codc. for thc pcrfornurncc of the work for which the Jrcrmit Ls issucd. _l havc and will maintain workcrs' compcnsation insurancc, as rcquircd by Section 3700 of the L:b<lr Codc, for the pcrlbrrnance of thc work for which this pcrmit is issucd. My workers' conlpcnsation insurancc camicr and policy nuntber arc: Policy Numbcr: Expires: _l cerlify that in the pcrformance of the work for which this permit is issued, I shall not cmploy any person in any manner so as to bccomc subjcct to the workers' compcnsation laws of California, and agrce that if I should bcconrc subjcct to ttrc workcrs' compcnsation provisions of Section 3700 of thc [:bor Code, I shall. forthwith comply with those provisions. WARNING: Failure to sccurc workers' comlrcnsation covcrage is unlawful. ard shall subject an cmploycr to siminal Jrcnalties and civil fincs up to one hundred thousand dollars ($100.000). in addition to the cost of compensation. danrages as providcd for the Scction 3076 of the [-ahrr Codc. intcrcst and attorncy's fccs. Date:-f M , I hcrcby nfllrrn under pnalty of pcrjury lhal I am liccnscd of Chapter 9 (contmcncing with Scclion 7Un) of Division 3 of the Busincss and hot'cssions Codc. and nty liccnsc is in tull and cffcct.t License Class: License Number: I ):rle: W t hcrcby afrirm ufflcr lEnalty of Frjury rhat th@ is tr consirudion lcnding 8gcrcy for thc pcrforrucc of thc work for which this tEmit ls is$cd (Sm. 3097. Civ. C.). [-cndcr's Namc: Lcndcr's Addrcss: APPLICANT NECLARATION I hocby alfirm undcr pcnalty of perjury one oI thc following dcclarations: Dcmolition Pcrmits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40. Part6) -Rcquircd lrttcr of Notification -.r. I ccrtifv that therT_ r ilAtccrtify thar I have fcdcralrcgulations regarding asbcstos renx>v:rlarc not applicablc to this projcct. read this application and slatc that the atxrve ordinanccs and Statc laws relating to building ahove nrntioncd propcrty for inspection Appliornt or Agenl Permitee neme tprintl: tK -- lhe Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenUl nsu latio n Roof Shear Wall Framing H / -1(- ?e Lc-.t*-fjtaa T2/) lnsulatio nlEnerqv Drywall Ext./lnt. Lath Brown Coat [\Iasonrv Pool Fence T-Bar Handicap Req. Deputy Final Report Enqineer Final Report Flood Zone Certif . I I ,Al ^n2 FINAL r tfft;]u hroU-ltt w'{ot Certificate of Occupancv I Notes, Remarks, Etc. 4 Rev. 08-07 -201 5 I -Dare t ?'7zdC