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\ BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcrcby affrm undcr lEnalty of pcrjury that I am excmpt fmm the ContrrctoN' Licensc lrw for lhc following r@sn (Stc.7031.5 Busincss anl Prcfcssion Crdc): Any City or County which rcquircs a Jrmil to conslnrt, sller, improve. dcmlish or lcIEir ey stnrcturc, prior to its Lssuucc. sl$ rcquircs thc opplicant for such Frmil to filc a signcd stalcmnt that he or she is liccnsd pusilt ro thc lmvisions of IIE Conlractor's Licenrd [:w (Chaptcr 9. Comrcing with S6tion 70m of Division 3 of the Busircss md Pmfcssions Codc) or that he or shc is cxctrpt thercfrom and thc basis for lhc allegcd cxemption. Any violation ofscction 70.1 1.5 by ony , applicant for . pcrmit subjets thc Bpplicant to r civil pcmlty of not mrc thm fivc hurdrcd dollus ($500). _1. as owner of thc prop,crty. or my cmployces with wagcs as thcir solc cornpcnsation. will do the work and the structurc ls not intcnclcd <lr oll'crcd for salc (Sec.7044. Business and Profcssions Codc: Thc Contraclor's Liccnsc l-aw docs not apply to an owner of thc proJrcrty who builds or intprovcs thcrccln, and who docs such work hirnsclf or hcrself or tfuough his or her own cmployees, providcd that such improvcmcnt.s arc not intcndcd oroffcrod for sah. lf, howcvcr. thc building or inprovcnrcnt is rcld wilhin one ),uu of complction, the Owncr Builder will havc thc burdcn of proving thd hc or shc did not build or improve thc proF,srty for thc purynse of salc). __1, as owncr of the property. am cxclusively contracting with licenscd contractors to construct thc project (Sec. 7W, Busincss and Prrofcsskrn Code: 'l'hc Contractor's License Law does not apply lo an owner of propcrty who builds or improves lhcrcon. and who conlracts for such projccts with a Contractor(s) licenscd pursuant to thc Contractor's License hw). -IamcxenrptundcrSc'ction-.B.&P.C.forthisrcason.Date:_0wner:_ WORKERS' COM PEtr'{SATION DECLARATION I hcrcby affirrn undcr Jrcnalty of prjury one o[ thc folklwirtg dcrlarations: _l havc and witl nraintain a Ccrtificatc of Conscnt to Sclf-lnsurc for workcrs' compcnsation. as provided for by Section 3700 of the Labor Code, tbr thc pcrformancc of tlrc work for which the permit ls issucd. _l havc and will maintain workers' compensation insurancc. as requircd by Section 3700 of thc l-abor Code, for thc pcrformance of for which this pcrmit is issucd. My workcrs' cornlrcnsation insurancc carricr and policy number arc:\ <-fatz ' 'thc work I)r>licy lL'Ll-24 -l certify that in thc performance of the work for which this pcrmit is issued. I shall not employ any pcrson in lhy runncr so as to bcconrc subjcct to thc workers'compcnsation laws of California, and agrcc that if I should bcconrc subjcct to thc workcrs' cornpensation provisions of Section 3700 of the l-:bor Codc, I shall, forthwith comply with thonc pmvisions. WARNING: I.hilure to sccurc workcrs' compcnsation coverage is unlawful. and shall subjcct an employer to criminal pcnaltics and civil fines up to onc hundrcd thousand dollars ($100.000). in addition to the cost of comlrcnsation. damagcs as provided for thc Scction 3076 of thc Lrbor Code. intcrcst and ort", lO - lS'b I hcrcby al'flrrn undcr Jrcnalty of pcrjury that I arn liccnscd of Chapter 9 (comrrcncing with Section 7000) of Division 3 of thc Busincss and hofcssions Codc, arxl rny licensc is in full forcc and effoct. Liccnsc Nurnbcr:Io ( o^tu, ul O '15'b W I hcrcby afftrm undcr JEnally of Frjury thd rhcrc is a consruction lcnding agcrcy for the pcrformcc of thc rcrk for which this Ismit i$ issucd (Ss. 3097, Civ. C.). Lcnrlcr's Nantc: knder's Address: APPLICANT NECLARATION I hcrcby affirnr undcr pcnalty of pcrjury onc of thc following dcclarations: Dcnrolition Pcrnrits-Asbestos Notification Fcdcral Rcgulations (Titlc 40. Part6) _Rcquircd Lctter of Notification _l ccrtity that thc fcderal rcgulations regarding asbcstos renxrvalarc not applicablc to this projcct. -l ccrtify that I have rcad this application and statc that with all City and County and County to enter upon thcordinances and Statc Lrws rclating to above nrcntioncd propcrty for Applicnnt or Agenl Pernritee name Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenVI nsu latio n Roof Sheathinq Shear Wall Framinq lnsulation/Energy Drvwall Ext./lnt. Lath Brown Coat JVlasonry Pool Fence T-Bar Handicap Req. Deputy Final Report Enoineer Final Report Flood Zone Certif I I .fr, FINAL ul2zlw lllz,ild,7,,f,:) Certificate of Occupancy I Notes, Remarks, Etc. Rev. 08-07 -201 5 ,",.. to-lf -20