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BUlLDlNG. INSPECTOR RECORD SITE-WORK DATE ID/SIG,COMMENTS Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bf loor/Ve nUl n s u I ation Roof Sheathinq Shear Wall Framing lnsulation/En ergy Drvwall Ext./lnt. Lath Brown Coat Masonry Poo! Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif I I \A _,,I FINAL l0lo L -L ') Y'|\trY't6Ltr61 Certificate of lv--I I Notes,Etc. orv NER tf tlt t.l)lrR I)r.1.(:A RA't'toN I hereby affirm under penalty of per.iury that I am exernpt from the Contractors' License Law firr the fotlowint reasondSr:c-7031.-5 Business antl Profession Cule): Any City or County which requires a prmir to construcr. atter, improve, a*q,f, n. ,.p?i, ,ny structure. prirr ttl its issuance. also requires the applicant for such Jrermit to file a signetl statetnent that he or she is licensed pur!il.tant to the provisions of the Contractor's Licensed Law (Chapter 9, Clommencing with .Section 7(XX) of Division -1 of the Business and PrtrfessionsCode)orthatheorsheisexempttherefromantlthebasisfrrrtheallegedexemption. AnyviotationofSectionT0.ll.5byany applicantforalrcrmitsubjectsthe applicanttoacivitpenaltyofnotrnrrethanfivehundreddollars($5(X)). -l.as ()wnerofthepnrperly.ormyernployeeswithw:lgesastheirsrlecornpensation.willdotheworkandthestnrctureisnot intended or offered frrr sah (Sec.7044. Business and Professions Crile: 'fhe Contractor's License Law does not apply to an owner of the proJrrty wlxr huilds or impnrves thercon, and whr does such work himself or herself or through his or her own employees, provitled that such imprrrvernents are not intended or offere<l frrr sale. lf. hrwever. tlre huilding or inpnrvenrnt is sold wilhin one year rlf crlntpletion. the Owner Buikler will have the burden of proving tturt he or she dkl not buikl or improve the pmperty forthe purJxrseof sah). I -1, asownerof the property. amexclusivelycrlntracting with licensetJ contractors to cons(ruct the pntject (Sec, 7044, Business and PnlfessirnCode: TheContractor's License Law does not applyto anowner of propertywho buildsor improves thereon. antl whrt contracts frrr such pn)jects with a Contractor(s) licensed pursuant to the Contractor's License Law). _l am exempt untler B. & P.C. for this reason. Dale:_0wner:_ WORKERS' COM PT'NSA'!'ION Dl.'CLARA'l'tON I hereby affirm under penalty of perjury one of the folkrwing declarations: -l have and will maintain a Certifrate of Consent to Self-lnsure firr wrrrkers' compensation. as pnrvided for by Section 3?(X) of the Labor Crile. frrr the performance of the work for which the perrnit is issued. -l have and will maintain workers' comJrcnsation insurance. as requiretl by Section 37fi) of the Lahor Code. for the grcrfrrrmance of the work ftrr which this permit is issued. My workers' compensation insurance carrier and policy number are: Policy Number: Expires: -l certify that in the Jrcrfirrmance of the work for which this permit is issuetl. I shall not employ any person in any manner so as to become subject to the workers'compensation laws of Califrrrnia. and agree that if I shoukl become subject to the workers' compensation provisions of .Section 37fi) of the latxrr Crxle, I shall, forthwith comply with those provisions. IVARNING: Failure to secure r.rrrrkers' civil fines up to one huntlrerl thrrusantl Section 3O76 of the Lahrr Crxle. interest ; comJrcnsation ls subject an employer to criminal penalties and tk r llars rrtltlit iolr of compensation. damages as providetl for the l)ate: I herehy aflirm under penalty of under of Chapter 9 (comrrncing with Section 7(XX)) of Division .1 of the Business and Professiuns and my license is in frrll frrrce and eft'ect. License Date: I hereby affirm under penalty of Jrrjury that issued (Sec, 3O97. Civ. C.). Lender's Name: ls agency ftlr the perfonnance of the wrrrk frrr which this permit is APPLICAN'I' DI.'CLARAI'ION I hereby affirrn under penalty of perjury one of the following tleclarations: Demolition Pennits-Asbestos Notification Federal Regulations (Title 40, Parr6) -Required Letter of Notification -I that regulations regarding asbestos renxrvalare not applicahle to this project. -I read this application and ahrve infrrrnntion is correct. I agree to comply with all City and County rlrtlinances nnd herehy au(hrriz.e representatives of this City and County t() enter ugrn the atxlve Applicnnt or Agent TI l'rrnrilre [-aws relating to huilding I [:]ev 08-07-201 5