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BUILDING- INSPECTOR RECORD SITE-WORK DATE ID/SIG COMMENTS Owner-Builder Declaration • I hereby affirm under penalty of perjury that I am exempt form the Contractors License Law for the followings reason(sec.703 I.;Business FForm acks and Profession Code):Any City or County which requires a permit to construct,alter,improve,demolish or repair any structure,prior to its issuance,also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the s/Steel/Holdowns Contractor's Licensed Law(Chapter 9,Commencing with Section 7000 of Division 3 of the Business and Professions Code)or that he or she is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the Erection Pads applicant to a civil penalty of not more than five hundred dollars(S500). U F E R Ground _I,as owner of the property,or my employees with wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Sec.7044,Business and Professions Code:The Contractor's License Law does not apply to an owner of the property SLAB Floor who builds or improves thereon,and who does such work himself or herself or through his or her own employees,provided that such who are not intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the Su bf l o o rNe n t/I n s u I. Owner-Builder will have the burden of proving that he or she not build or improve for the purpose of sale). Roof S heath i n _I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and gProfession Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who Shear Wall contracts for such projects with a Contractor(s)licensed pursuant to the Contractor's License Law.). xempt under Section ,B.&P.C. or this reason. Framing — L ,- Insulation/Energy Date. d owne D rywa I I WORKERS COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: Ext./I nt. Lath _I have and will maintain a Certificate of Consent to Self-Insure for workers'compensation,as provided for by Section 3700 of the Brown Coat Labor Code,for the performance of the work for which the permit is issued. Mason _I have and will maintain workers' compensation insurance,as required by Section 3700 of the Labor Code,for the performance of the Masonry work for which this permit is issued.My workers'compensation insurance carrier and policy number are: Pool Fence Carrier: T-Bar Policy;'umber: Expires: Handicap Req. (This section need not be completed if the permit is for One hundred dollars(S100)or less) Deputy Final Report _I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to py became subject to the workers'compensation laws of California,and agree that if I should become subject to the workers' Engineer Final Report compensatgpn provisions o Section 3700 of the Labor Code,I shall,forthwith comply with those provisions.. t%Flood Zone Certif. Da Applicant: WA �1LING:Failure to secure workers'compensation coverage is unlawful,and shall subject an employer to crir;inal penalties and civil fines up to one hundred thousand dollars(S100,0W),in addition to the cost of compensation,damages as provided for the Section 3076 of the Labor Code,interest and anorney's fees. FINAL U LICENSED CONTRACTORS DECLARATION I hereby affirm under penalty of perjury that I am licensed under provision of Chapter 9(commencing with Section 7000)of Division 3 of Certificate of Occupancy the Business and Professions Code,and my license is in full force and effect. Notes, Remarks, Etc. License Class: License Number Date, Contractor: CONSTRUCTION LENDING AGENCY I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is issued(Sec.3097,Civ.C.). Lender's Name: Lender's Address: APPLICANT'S DECLARATION Demolition Permits-Asbestos Notification Federal Regulations(Title 40,Part 6) _Required Letter of Notification _I certify that the federal regulations regarding asbestos removal are not applicable to this project. I certify that I have read this application and state that the above information is correct.I agree to comply with all City and County ordinances and State Laws relating to building construction,and hereby authorize representatives of this City and County to enter upon the above mentioned property for inspection purposes. O Applicant or agent sig.\ '� ` � Date: Permittee name(prin�T �Jk th,V,C-0 e�B'R -V� M:\WP51\Permit-Inspection Forms\Building-Inspection Record.doc 03,31.06