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BUILDING- INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcreby affirm under pcnalty of perjury that I am cxempt from tlrc Contractors' License law for t]re following reason (Scc.7031.5 Busincss arxl Profession Codc): Any City or County which requircs a pcrmit to conslruct, altcr. improve. demolish or rc1nir any structure. prior to its issuance, also rcquires the applicant for such pcrmit to filc a signcd statcment that hc or shc ls licensed pursuant t<l the provisions of the Contractor's Licensed Law (Chapler 9, Comrrrencing with Scrction 7000 of Division 3 of the Busincss and Profcssions Code) or that he or shc is excmpt thercfrom and thc basls for the allcged excmption. Any violation of Section 7031.5 by any applicant for a pcrmit subjccts the applicant to a civil pcnalty of not morc than fivc hundred dollars ($500). _1. as owrrcr of thc propcrty. or nly employces with wagcs as thcir solc compcnsalion. will do the work and thc stnrcttnc is not intended or offercd for salc (Scc.7O14. Busincss and hofcssions Codc: Thc Contraclor's Licensc [:w docs not apply lo an owncr of thc propcrty who huilds or improves thcreon and who docs such work hirnsclf or hcrsclf or through his or her own employecs. providcd that such imlnovcnrcnts arc not intcnded orofl'ered f<rr salc. lf, howerrcr. thc buihing or inprovcnrnt is sokl within onc )car of comphtion, thc Owncr Buiklcr will havc thc burdcn of proving that hc or shc did not buikl or improvc thc proprty for thc purpnse of salc). __1, as owncr of the pmperty. arn exclusivcly contracting with licensed contraclors lo conslruct thc pro.icct (Scc. 7044, Business and Profession C<de: Thc Contractor's License Law docs not apply to sn owncr of property who builds or improves thcreon. and who conlracts for such projccts with a Contraclor(s) liccnscd pursuant to the Conlraclor's Liccnse Law). -IamexcmptundcrScction-.B.&P.C.forthisreason.Date: Owner: WORKEP-S' COM PENSATION DECLARATION I hercby affirrn under Jrenalty of pcrjury one of thc following declarations: _l have and will maintain a Ccrtificatc of Conscnt to Self-lnsurc for workers' compensation. as providcd for by Sc.ction 3700 of thc [:bor Codc. for the perfornrance of thc work for which the pcrmit ls issued. _l hlw and will maintain workcm' comJrnsation insuramc. as rc{uircd by Scction 37U) of thc libor Codc. for the performre of ! thc work for which this Fnnit is issucd. My workcrs' oryrcnsation insumncc canicr arxl plicy numbcr uc: tA*n^,t(con Z^ric\^ Policy Nrr'lrt*r Expiles:\z-3t.?o _l ccrtify that in thc pcrfornurce of thc work for which lhis pcrrrrit is issucd. I shall not ernploy any pcrson in any manner so as to bcconrc subjcct to the workcrs'compcnsation laws of California, and agrcc that workcrs' compcnsation provisions of Scction 37fi) of thc L:bor Code. I shall. forthwith if I should beconrc subject to thc with thosc pnrvisiorrs. WARNING: Failurc to securc workcrs'conrpcnsation covcragc is unlawl'ul.an enrploycr to criminal pcrraltics and civil fines up to onc hundrcd thousand dollars ($100.000). in addition to ion. danuages as providcd for the .Section 3076 of the Labor Code" intcrcst and fees. l )ale:lo-tq -c) L- I hcrcby aflirm under pcnalty of perjury that I arn provlsron Chaptcr 9 (cornmncing with Scrtion 7000) of Division 3 of the Busincss and hofcssions Code. and my is in full forcc and cffect. . L-34 oq, ILiccnse Date: Numbcr:v(u-(q-/'7All 44r.'seu){ tt v g I hercby sffEm urdcr penslty of pcrjury that therc is a @nsruclion hnding agercy for the perfmc of the wtrk for whbh this Ismit b isscd (Sc. 3097. Civ. C.). kndcr's Nam: [-cndcr's Addrcss: APPLICANT NECLARATION I tucby aflirm under pcnalty of perjury onc of thc following dcclarations: Dcnrolition Permits-Asbcstos Notification Fcdcral Regulations (Title 40. Part6) -Requircd Lrttcr of Notification _l ccrtify that thc fedcralrcgulations rcgarding asbcstos rcmovalare nol applicablc to this projcrt. and slatc that thc is corrcct. I agrcrc to corrrply with all City and County rcprcscntativcs of this City and Counly lo cnler upon thc abovc rnentionccl propcrty lbr inspcction Applicant or Agenl I Pernrilee n&me constnrction. w ,,r", lo- [Q- 7 d Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenVl nsu I atio n Roof Sheathing /O'/5'r€gfrU.l6 i4 rI7 Shear Wall Framino lnsulation/Enerqy Drywall Ext./lnt. Lath Brown Coat lt/asonry Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif I I FINAL ll I Al 'r,r 0ktr a I Certificate of Occupancy Notes, Remarks, Etc Rev. 08-07-201 5 co*@