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BUILDING- INSPECTOR RECORD Flev. 08-07-201 SITE-WORK DATE ID/S!G.COMMENTS Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bf loor/Ve nt/l nsu I atio n Roof Sheathins Shear Wall Framinq lnsu lation/Enerqy Drvwall Ext./lnt. Lath Brown Coat [\/asonry Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif I Certificate of FINAL Notes, Remarks, Etc. OWNER BUI LDE,R DEI,CA RA'I'ION I hereby affirm untler penalty of perjury that I am exempt from the Contractors' License l-aw firr the following reason (.Sec.7031.5 Business and Profession Crxle): Any City or County which requires a prmit to construct, alter, improve. dermlish or repair any structure. prirlr to its issuance, also requires the applicant for such Jrerrnit to file a signe<t staterEnt that he rlr she is licensed pursuant to the pnlvisions of the Contractor's Licensed Law (Chapter 9, Commencing with ,Section 7fiD of Division -3 of the Business and ProfessionsCrxle)orthatheorsheisexempttherefromandthehasisfortheallegedexemption. AnyviolatirtnofSectionT03l.5byany applicant for a pernrit suhjects the applicant to a civil penalty of not rnrre than five hundred dollars ($5tXt1. _1, as owner of the property, or my employees with wages as their srh compensat ion. will do the work and the structure is not intended or offeretl frrr sale (Sec.7O44. Business and hofessions Code: The Ctrntractor's License Law does not apply to an owner of the proJrerty whr tnrilds or impnrves thereon, and who tloes such wrrrk himself or herself or through his or her own empkryees. provitled that such improvernents are not intended oroffered firr sah. If. hrwever. the huikling or inTrrovenrnt is sold within ('rne )Ear of completion, the Owner Buikler will have the hurden of proving that he or she ditl not buikl or impmve the prof,erty for the pur;xrseof sale). _1. as owner of the property. am exclusively contracting with licensetl contract()rs t() construct the project (Sec. 7044. Business antl ltofessirnCode:'fheContractor'sLicenseLawdoesnotapplytoanownerofpropertywhobuildsorimprovesthereon. and who contracts for such pnrjects with a Contractor(s) licensed pursuant to lhe Contraclor's License Law). -IamexemptunderSectirln-.B.&P'C.ftlrthisreason. I)ute:( )u ltcr. WORKERS' C(rMI'ENSA'|.ION DECLAITA'I'ION I herehy affirm under penalty of perjury one of the following declarations: -lhaveandwill maintainaCertifrcateofConsenttoSelf-lnsureftrrworkers'compensation.as pnlvidedforhySection.ST(X)ofthe L^ahor Crxle, for the perfirrmance of the wrlrk frrr which the permit is issued. _lhaveantlwill maintainworkers'compensationinsurance.as requiredhy.Section3T(X)ofthel,aborCode,fortheperformanceof the work for which this permit is issued. My workers' compensation insurance carrier and grlicy number are: Carrier: Policy _l certify that in the Jrerfrrrmance of the work for which this perrnit is issuetl. I shall not empkry any person in any manner s() astobeconrsuhjectlolheworkers'compensationlawsofCalifrrrnia.anttagreethatif lshluldhecomesuhjecttothe workers' compensation provisions of Section .17(X) of the Lrtxrr Crxle. I shall. forthwith comply with those pnrvisions. WARNIN(): Failure to secure workers' compensntion coverage is unlau,ful. and shall suh.iect an employer ttl criminal Jrnalties antl civil fines up to one hundred thousantl tkrllars ($l(n,(XX)). in addition to the cost of compensalion, damages as provided for the .Section 3076 of the Lahrr Cotle. interest and attorney's fees. l)ate : Applic:rnt: LICENSED CONI'RAC'I'OR DTCLARAI'ION I hereby affirm under penalty of Jrcrjury that I am licensed under provision of Chapter 9 (comnrncing with Section 7Un) of Division 3 of the Business and hofesskrns Code. and my license is in full frrrce antl effect. License Nunrber: CONSI'RUC'I'ION LENDING AGENCY I hercby aflirm under Jrnalty of perjury that there is a construction hnrling agency for the perfrrrmance of the work for which this Jrermit is issued (Sec. 3()97, Civ. C.). Lender's Name: I )atr:: ('onlr:tctor: Lender's Aeldress: A PPLICAN'I' IIL,CLAR A'TTON I her$y affnm under penalty of grcrjury one of the following declarations: Derrxllition Permits-Asbestos Notification Federal Regulations (Title 4O. Part6) -Required Letter of Notification _l certify that the federalregulations regarding tsbestos renrrvalare not applicahle lrt this project. -l certify that I have read this application and state that the atxrve information is conect. I agree to comply with all City and County onlinances and State Laws relating to building construction, and herehy authrriz.e representatives of this City and County to enter uJxrn the above mentioned property frrr insJrcction purynses. Applicant or Agent Signaturt: Date:- a