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BUILDING- INSPECTOR RECORD SITE-WORK DATE ID/SIG,COMMENTS OWNER BUILDER DELCARATION I hcrcby affirrn under penalty of pcrjury that I am cxcmpt from thc Contractors' License [:w for the following rcason (Scc.7031.5 Business and Profession Codc): Any City or County which rcquires a permit to conslrucl. altcr, improvc, &molish or rcJrair any structure. prior to its issuancc. also rcquircs thc applicant for such pcrmit to lilc a signcd stalcnrent lhat hc or shc is licenscd pursuant to thc provisions of thc Contractor's Liccnsed Law (Chapter 9, Commencing with Scrtion 7000 of Division 3 of thc Busincss and Prol'cssions Codc) or that hc or she is cxempt thercfrom and the basis for thc alleged exemption. Any violation of Section 7031.5 by any applicant for a Jrcrmit subjcrcts the applicant to a civil pcnalty of not morc than fivc hundrcd dollars ($500). _1, as owncr of thc propcrty, or my enrployees with wages as their sole compcnsation, willdo thc work and the suucturc is rct intcndcd or offered for salc (Sec.7M4. Busincss and Prol'cssions Code: The Contractor's Liccnse law does not apply to an owner of thc proprty who builds or improves thcrcnn. and who docs such work hirnsclf or hcrcelf or through his or hcr own employees, providcd that such improvcnrcnts arc not intendcd or oflbrcd for sah. If. howcrrr. thc building or inprovcnEnt is rcld wilhin onc )trr of comphtion, thc Owncr Builder will havc thc burdcn of proving that hc or she did not buih or improve tlrc propcrty for thc purposc of sah). _1. as owncr of the pnopcrty. am exclusively contracting with licenscd contractors to construct thc pro.icrct (Sec. 7W, Busincss and Protcsskrn Code: The Contractor's License Law does not apply to an owner of property who builds or improves thcrcon. and who contracts for such projccts with a Contractor(s) liccnscd pursuant to the Contraclor's Licensc Law). I am excnrnt under Scction . B. & P.C. for this rcason. Date:- Owner:- WORKER.S' COMPENSATION DECLARATION I hcreby affirrn undcr penalty of perjury one of the following dcclarations: _l have and willmaintain a Certificate of Consent to Self-lnsurc for workcrs'compensation, as providcd for bySection 3700 of the labor Codc, for thc pcrfornunce of the work for which the permit is issued. _l have and will maintain workers' com;rcnsation insurance, as required by Scction 3700 of the l,abor Code. for the lrcrformance of thc work for which this permit is issuod. My workcrs' coq)ensalion insurancc carricr and policy numbcr arc: Policy Numbcr: Expires: _l certify that in thc pcrformance of the work for which this pcrmit is issucd. I shall not cmploy any pcrson in any runnncr so as to bccomc subject to the workcrs' compcnsation laws of California, and agrcc that if I should bcconrc subict to thc workcrs' corrrpcnsation provisions of Scction 3700 of thc [:bor Codc. I shall. forthwith comply with those provisions. WARNING: Fhilure to sccurc workers' compcnsation coverage is unlawful, and shall subjcct an employcr to crirninal grcnaltics and civil fincs up to onc hundrcd thousiurd dollars ($100,000), in addition to thc cost of compcnsation. damages as provided for lhc Scction 3076 of lhc l-:bor Code. intercst and attorncy's fccs. Date:__ __ LICENSED CONTRACTOR DECL TTATION I hcrcby alfirm under pcnalty of perjury that I am liccnscd under provision of Chapter 9 (comnrcncing with Soction 7000) of Division 3 of the Busincss and hofessions Codc. arxl my license is in full force and cffcct. Liccnsc Number:Liccnse Class: l Date:___( 'ortl r:tt'lrlr. W I hcrcby afhrm urdcr lEnalty of pcrjury that therc is a mnsruction hnding 8gcrcy for the Isformc of thc work for which this lErmit is issucd (Sec. 3097, Civ. C.). lrndcr's Nanrc: APPLICANT DECLARATION I hcrcty affirmundcr pcnalty of prjury onc of thc following declarations: Dcmolition Permits-Asbcstos Notilication Fcderal Rcgulations (Titlc 40. Part6) -Requircd lrtter of Notification __l ccrtity that thc fedcralrcgulations rcgarding asbcstos rcnxrvalarc not applicablc to this projcrt. _l certity that I havc rcad this application and statc that thc atnvc' infonnation is corrcct. I agrec to comply with all City and County ordinances and Statc laws rclating to building construction and hcrcby authorizc abovc rncntioncd proJrcrty for Applicanl or Agent Permitee nanre ivcs of this City and County lo cntcr upnn lhc Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Subf loo rlY enV Insulation Roof Sheathins Shear Wall Framing lnsulation/Enerqy Drywall Ext./lnt. Lath Brown Coat [\Iasonry Pool Fence T-Bar Handicap Req Deputy Final Report Enoineer Final Report Flood Zone Certif ,1 FINAL tt Ir -@ -D*d-fl Certificate of Occupancv ,a Notes, Remarks, Etc. Rev. 08-07-201 5 Applicant: _Dare: lt/to/zr/,