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BUILDING- INSPECTOR RECORD SITE-WORK DATE ID/SIG.COMMENTS OWIIER BUILDER DELCARATION I hcrcby affirrn undcr pnalty of perjury that I am cxcmpt from thc Contractors' Liccnse Law for the following reason (Scc.7031.5 Busincss and Profcssion Codc): Any City or County which rcquircs a pcrmit to conslruct. altcr. improvc. dcmolish or rcpir any struclurc, prior to its issuarrce. also rcquircs thc applicant for such permit to file a signcd slatcmcnt that hc or shc Ls liccnsed pursuant to the provisions of ttrc Contractor's Licenscd [:w (Chapter 9, Comrnencing with Scrtion 7000 of Division 3 of the Business and Profcssions Codc) or that he or shc is exempt thcrefrorn and thc basis for the allcgcd exemption. Any violation of Scction 7031.5 by any applicant for a permit zubjcrcts the applicant to a civil penalty of not more than five hundred dollars ($500). _1. as owner of the propcrty, or my employees with wagcs as their solc compcnsation, willdo thc work and thc struclurc is not intcnded or offcrcd for salc (Scc.7G[4, Busincss and hofcssions Code: The Contractor's Liccnsc l,aw docs not apply to an owner of the proprty who builds or improvcs thercon. and who does such work himself or herself or thrcugh his or her own cmployees. providcd that such improvcmcnts arc not intcndcd or oficrcd for sale. I[, howcrrcr. thc building or inqlrovenrcnt is sold within one ]car of cornplction. thc Owncr Buildcr will havc thc burdcn of proving that hc or she did not build or improvc thc propcrty for the pur;nsc of salc). _1. as owncr of thc property. am cxclusivcly contracting with liccnsed contractors lo conslruct thc project (Scc. 7U4, Business and Profcssion Code: Thc Contraclor's Licensc Law docs not apply to an owncr of propcrly who builds or improves thercon. and who contracts for such projccts with a Glntractor(s) liccnsed pursuant to thc Contractor's Licensc [,trw). _ _l anr cxcnrpt under Scction_. B. & P.C. for this reason. Date:()u'ner: WORKERS' COMPENSATI()N DECL^ RATION I hcrchy affirm under penalty of pcrjury onc of thc following dcrclarations: '-l have and will maintain a Certificatc of C<lnscnt to Sclf-lnsure for workcrs' compensation. as providcd for by Section 3700 of the Labor Codc. for the pcrforrnance of thc work for which the frcrmit Ls issued. {,r 1 thc havcandwill maintainworkcrs'conrpcnsatiorrinsurancc.as rcquircdbyScction3Tfi)oflhcLaborCode,fortheperformanceof work for which this permit is issucxl. My workcrs' cornpensation insurance carricr arxl policy numbcr arc: /0 / t /"-c,t-t _l ccilify that in lhc pcrformrcc of thc work for which this Frmit is issucd" I shall uol cmploy any prson in oy mner s as Io be@m subjcrt to the uqkc6 comlrcnstion laws of C{lifomi., ild agrc that if I should bccorc suhj$t to ilE workcN cotr{rcLerionpmvisiomofScction3T0Oofthct2borCo&.lslBll.fonhwirh@mplywithlhosprcvisions. WARNING: Failurc to *curc udkcrs' @r{rcnstion covssgc is unlaeful. and shsll subjsl dn cmploycr to cimiml penaltls and . civil fircs up to orc hundrcd tlbusmd dolles ($100.(m). in addition 10 the cost of cotr{Enstion. damges as provilcd for thc 3076 of l,atnr Codc. intercst and allorncy's fecs. NECLARATION I hcrcby affirm under penalty of pcrjury that I am licenscd undcr provision of Chaptcr 9 (contnpncing with Sccti<ln 7000) of Division 3 of thc Business and Professions Code. and my license is in full force and effcct. Nulnbcr: Conlraclor:krcu-* I bl Qtt ale c_J CONSTRUCTION LFTYDING AG EN CY I hcrcby alfirm uMcr IEnBlty of Frjury that lhcrc is a construction hnding agcmy for lhc Frformcc of thc work for which this permit is issued (Sec. 3097. Civ. C.). lrndcr's Namc: Lcnder's Addrcss: APPI ICAXT neCtlRlrrn I hocby aftinn undcr penalty of pcrjury onc of thc following declarations: Dcrnolition Permits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40, Part6) -Rcquircd l,ctter of Notification -l ccrlify that thc fcdcnl rcgulslions rcgading asbcslos rcmval arc nol applicoblc lo this pmj@1. f$ccnify rnut I Mvc ]ead this spptication srd statc that thc ahovc infomlion is offi. I agre to corryly with all City and County Afilnares and Statc Laws rclating to building constructiotr dd hcrcby authorirc reprc*ntativcs of this Cily rnd County to oter ulEn the abovc mntioncd prcperty for inqrction purJns. f,ppn"urt or Agent o*", /o/>q{Lo \Pcmlc,*rerirl ffar,ztsr) C),I,xa\ Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenUl ns u latio n Roof Sheathinq Shear Wall Framinq lnsulatio nlEnergy Drywal! Ext./lnt. Lath Brown Coat Jtlasonrv Pool Fence ( T-Bar Handicap Req. Deputy Final Report Enqineer Fina! Report Flood Zone Certif FINAL t)l/o lp DfrVtr Gertificate of Occupancv Notes, Remarks, Etc. 1 / Rev. 08-07-201 5 ?7nqt L.