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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNIiR BUILDER DEI,CARATION I hcreby affirnr under penalty of perjury that I am exempt from the Cbntractors' l-icense l-aw for the following rcason (Sec.7031.5 Business and Prol'cssion Code): Any City or County which requires a permit to construct. alter, improve, dermlish or repair any strucrure, prior to its issuancc. also rcquires the applicant for such pernit to fih a sigrred .slaternent that hc or she is licensed pursuanl to thc provisions of thc Contraclor's l.icensed law (Chapter 9. Commencing with .Scction 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 Sectbn 7031.5 by any . applicant for a perrnit subjcct.s thc applicant to a civil penalty of not nnre than five hundrcd dollars ($5001. _1. as owncr of thc property. or my cmployees with wages a.s their sole compcnsation, will do the work and the structure is mt interxletl or offered for sale (Scc'.7(X4, Business and Profession.s Codc: The Contractor's Liccnsc Law tlocs not apply to an owner of the property who builds or improves thereon and who does such work himself or herself or lhrough his or her own employees, providcd that such improvenrcnts are not intended or ollered for sale. Il. however, thc building or irprovenrcnt is soH wilhin one ),ear of conrpletion, thc Owncr Buikbr will have the burden of proving that hc or shc did not builJ or improvc ttrc propaty for the purposc of sale). _1. as owner of the property, am cxclusively contracting with licensed conlr&clors to conslruct the pmjcct (Sec. 7044, Busincss and Prollssion Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon. and who contracts for such projects with a Contractor{s) licensed pursuant to thc Contractor's License t aw). -IamexemptunderSection-'B.&P.C.lbrthi.sreason.Dale: WORKERS' COMPI:NSATION DECLARATION I hercby aflirm under pcnalty of perjury one of the following declarations: _l have ard will maintain a Certifrcate of Consent to Self-lnsurc for workers' compcnsalion, as provided for by Section 3700 of the Labor Code. for the pcrformance ofthe work lor which the pcrmit ls issued. Kand will maintain workers' compensation insurance, as required by Section 3700 of the l-abor Code, for the perfonnancc of thc work tbr whiclr this prmit is issuct.workers' compcnsation insurancc carricr arxl gtlicy numbcr are: te Policy ZI not enrploy any lrcrson in any mannet if I should become subjcct to the comply with those provisions. WARNING: Failurt: to sccurc workcrs'comlrcnsation coverage is unlawful, antl shall subjcct an cmployer to criminal pcnalties and civil lines up to one hundrcd thousand dollars ($l00.Um), in addition to the cosl of cornlrcnsation, damages as provided for thc Section 3076 of the l-abor Code, interest and attorney's I hereby allirrn undcr pcnalty of perjury that I am licensed ol'Chaptcr 9 (cornrnencing with Section 7000) of f)ivision 3 of the Busincss and Professions Codc, anl my license is in full force arxl clfect. License B Numbcr:36 3/ I hercby atlirm under pnalty of perjury tlut there is a construction lending agency frrr the performance of the work lbr which this permit ls issuccl (.Scc. 3097, Civ. C.). Lendcr's Nanrc: knder's Address: APPLICANT DECLARATION I My affrm under penalty of pcrjury one of the following declarations: Denrolition Permits-Asbestos Notification Federal Regulations (Titlc 40, Part6) -Required lrtter of Notification _l certity that thc federal regulations rcgarding asbestos renmval are not applicable to this projcrt. state that the above information is correct. I with all City and County and County to enter upon thc atxlvc mcntionctl propcrty lirr inspcction Applicant or Agcnt \ Pemritee nanlr orru, ?- / - Zb Set Backs I Ir-, Forms/Steel/Holdowns qlttlze Wru ,-T Erection Pads U UFER Ground SLAB Floor Su bf loor/Ve nVl nsu latio n Roof Sheathinq Shear Wall I Framino hlz.t ltu)0tf7r2 2 lnsulation/Enerqv l- t / Dqtwall (ExJlllnt. Lath lol?.1 lu)An-Ht l- Erown Coat Jt/asonry Pool Fence T-Bar Handicap Req. Deputy Final Report Enqineer Fina! Report Flood Zone Certif I FINAL tt I4/t o DA'+r Certificate of Occupancy Notes, Remarks, Etc. Rev. 08-07-2015 7 orr* Q- /- L2 J