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BUILDING- INSPECTOR RECORD SITE.WORK DATE ID/S?G..,.COMMENTS Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bf loo r/VenUI ns u Iatio n Roof Sheathing Shear Wall Framing lnsulatio nlEnerqy Drvwall Ext./lnt. Lath Brown Coat J\Iasonry Pool Fence T-Bar Handicap Req. Deputy Final Report Enqineer Final Report ffiood Zone Certif.I 2t {lUUTtnqC o t',2et YUo{otg'\, 0 t" A.&rCFINALtt7n Certificate of Occupancv t Notes, Remarks, Etc. DIiI,CARA'I'I()N I hcreby affirm undcr pnalty of pcrjury that I am cxcmpt from the Contractors' License law for thc following reason (Sec.7031.5 Busincss arxl Profcssion Ccxlc): Any City or County which requircs a pcrmit to construct. ahcr, improve, demolish or repair any structurc, prior to its issuance. also rcquires the applicant for such pcrrnit to file a signcd slatement that hc or shc is liccnscd pursuanl to the provisions of thc Contractor's Licensed kw (Chaptcr 9. Commcrrcing with Scrction 7000 of Division 3 of the Business and Professions Codc) or that hc or she is cxenrpt thcrcfrom and thc basls for the allegcd cxcmption. Any violation of Scction 703 I .5 by any applicant for a 1rcrmit subjects thc applicant to a civil pcnalty of not morc than fivc hundred dollars (S500). __1. es owncr of thc prof,crty. or my employees with wagcs as thcir solc comJrcnsation. willdc, thc work ard thc stnrturc is not intendcd or offcrcd for salc (Sc.c.7044. Busincss and Professions Code: The Contractor's Liccnse law d<res not apply to an owncr of the propcrty who builds or improvcs thcreon and who does such work himself or herself or through his or hcr own employecs. providcd that such imlnovcnrcnts are not intcndod oroffered for salc. If. however. thc building or ingrrovcnrcnt is sold within onc ysr of complction, lhc Owncr Buildcr will havc thc burdcn of proving that hc or she did not build or improvc thc proprty for thc purpose of salc). _1, as owncr of thc propcrty. am cxclusivcly contracting with liccnscd contraclors lo conslruct the projcrct (Sec. 7U4, Busirrcss and Prrofc.ssion Code: Thc Contractor's Liccnsc Law docs not opply to an owner of property who builds or intproves thercon, and who conlracts tbr such pojccts with a C-ontractor(s) liccnscd pursuanl to thc Contraclor's License l-aw). -l am excmpt undcr Scction-. B. & P.C. for this reason. Dale:--__ Owner:_wonm DECI ARATION I hercby affirm undcr penalty of pcrjury one of the following declarations: __l have and will maintain a Ccrtificate of Conscnt to Sclf-lnsure l'or workcrs' compcnsation. as povided for by Section 3700 of thc Labor Codc. for the perfornrancc of thc work for which thc permit Ls issued. $9,uu" r',,t 3700 of thc Lrbor Codc. for the pcrfornrance of thc work for and policy nurnbcr arc: tro b0 \\/tlzo that in the pcrfornurcc of thc work for which this permit is issucd. I shall not enploy any person in any nnnner so as to becomc subjcct to thc workcrs' compensati<ln laws of California. and agrec that if I should bcconrc subjcct to thc workcrs' compcnsation provisions of Section 3700 of thc l-abor Code. I shall. Ibrthwith comply with thosc provisions. WARNING: Failure to sccurc workcrs' compcnsation coverage is unlawful. and shall subjcct an cnrploycr to crirrrinal pcnalties and civil fincs up to one hundrcd thousand dollars ($100.fin). in addition to thc cost o[compcnsation. darnagcs as providcd f<rr thc Scction Date:_ intercst and attorrrcy'sq I hcrcby afllrnr unclcr perralty of pcrjury that I am liccnscd 9 (conurcncing with Section 70m) of Division 3 of the Busincss and Profcssiorrs Code, and my liccnse is in full force and effcct. Licerrse o Nurnbcr:€bv\o\r W I hcrcby amrm undcr lEnrltyof Frjury thor therc is a construction lcnding a8crcy for thc pcrformc of the work for which Ihis Frmit is issued (Scc. 3097, Civ. C.). lrndcr's Narrrc: [-ender's Address: APPLICANT DECLARATI(TN I hocby aflirm undcr pcnalty of pcrjury onc of thc following dcclarations: Demolition Pcrmits-Asbestos Notification Fcderal Rcgulations (Titlc 40. Part6) -Requircd l-cttcr of Notifrcation _l certify that the fcdcral rcgulations rcgiuding asbcstos renroval arc nol applicablc to lhis projcrct. that I have read this applic'ation and state that thc akrvc information is concct. I agrc.c to comply with all City and County ordinanccs and State [-aws relating to building construction and hcrcby authorizr reprcscntativcs of this City and County .cntcr ulnn thc above nrentioned property for ,\pplicanl or Agettt Pernritee name q LL LO Rev. 08-07-201 5 a I Applicant: