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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNBR BUILDER DELCARATION I hcrcby atfirm undcr pcnalty of perjury that I iun excmpt from the Contractors' Licensc law for thc following reason (Sec.7031.5 Business arrd Profcssion Codc): Any City or County which rcquircs a pcrmit to construct, altcr, improve. demolish or repair any structurc, prior to its issuance. also rcquircs thc applicant for such pcrrnit to tile a signed statemcnt that hc or she is licensed pursuant to the provisions of thc Contractor's Licensed Law (Chapter 9, Commencing with Scctiott 7000 of Division 3 of thc Business and Profcssions Code) or that hc or she is exempt therefrom and thc basis for the alleged exemption. Any violation of Section 7031 .5 by any applicant tbr a perrnit subjects thc applicant to a civilpcnalty of not more than t'ivc hundrcd dollars ($5001. _1. as owncr of thc propny, or my cmployccs with wagcs as thcir sole comJrcnsation, willdo thc work and the structurc is not intcndcd or olTcred for salc (Scc.7044, Busincss and Professions Codc: The Contractor's Liccnsc [:w does not apply to an owner of thc prcperty who builds or inrprovcs thcrcon. and who does such work himself or hersclf or through his or her own employees. providcd that such improvcments arc not intcndcd or offerod for salc. If, howcvcr. thc buikling or inqrrovcrncnt is sold within onc yeir of complction. the Owner Builder will havc thc burdcn of proving that hc or shc did not build or improve the property for the purynsc of salc). _1, as owncr of thc propcrty. am cxclusively contracting with liccnsed contractors to construct the projcct (Scc. 7044. Busincss and Profcsskln Codc: The Contraclor's Liccnsc Law docs not apply to an owner of propcrty who builds or improvcs thereon, and who contracts for such projccts with a Contractor(s) licenscd pursuant to thc Contractor's Liccnsc t aw). -l anr cxempt under Section-. B. & P.C. for this reason. lt^r -. WORKER.S' COMPENSATION DECLARATION I hcrcby affirrn undcr pcnalty of perjury onc of the following dcclarations: _l havc urd will maintain a Certificate of Conserrt to Sclf-lnsurc for workers' compcnsation, as providcd for by Section 3700 of the l,abor Code. for thc pcrformance of thc work for which the permit is issucd. _l havc and will rnaintain workers' compensation insurance, as rccluircd by Section 3700 of the Labor Codc, for the perfornunce o[ thc work for which this pcrrnit is issucd. My workcrs' conrpensation insurancc carricr and policy number arc: Carrier: Policy _l certify that in thc grcrformancc of thc work for which this prrnit is issued, I shall not employ any pcrson in any manner so as to bccomc subjcct to the workers' compensation laws of California, and agree that if I should bccome subject to thc workcrs' corrrpcnsation provisions of Section 3700 of thc L:tnr Codc. I shall. forthwith cornply with those provisions. WARNING: Failure to sccure workcrs' compensation covcrage is unlawful. and shall subject an employer to criminal ;rcnalties and civil fines up to onc hundred thousand dollars ($100.0tt01, in addition to the cost of compensation, darnages as provided for the Scction 3076 of thc Labor Code. intcrest and attorncy's fces. Aonlicanl: LICENSED CONTRACTOR DTCLARATION I hercby affirm undcr pnalty of perjury that I arn licenscd under provision of Chapter 9 (comnrcncing with Section 7000) of Division 3 of the Business and Professions Codc. and my licensc is in full force and effect. License Class: Liccnsc Number: Date: W I lrcrcby affirm undcr Fnalty of Frjury thar thcrc is a construction lcndif,g agcncy for thc lrcrforlllmc of the work for which this Fnnit is issucd (Scc. 3097, Civ. C.). l,cnder's Namc: lrndcr's Address: APPI ICANT DECLARATION I lrcrcby allirm under pcnalty of pcrjury onc of thc following declarations: Dcmolition Pcrmits-Asbestos Notification Fcdcral Regulations (Title 40. Pan6) -Rcquired lrtter of Notification _l ccrtify that thc fedcral rcgulations rcgarding asbcstos rcmovalarc not applicablc to this projcct. -l certify that I have rcad this application and state that the otdinanccs and Statc laws relating abovc mcntioncd properly for Applicant or Agent Perrrrilec na[re construction,the Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenVl nsu latio n Roof Sheathinq Shear Wall Framing lnsulation/Eneroy Drywall Ext./lnt. Lath Brown Coat [\Iasonry Pool Fence T-Bar Handicap Req. Deputv Final Report Engineer Final Report Flood Zone Certif FINAL t(? Certificate of Occupancv I Notes, Remarks, Etc Rev. 08-07-201 5 t), **, Wo/=oro