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BU!LDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I haeby affirm undo penalty of perjury that I m excmpt from thc Contrsctors' License Law for thc followinS r@n (Se.7031.5 Busin6s and Profsion Code): Any City or County which rcquirc a pcmil to @ngrud, altq. improv€, donolish or repair uy structurc. prior to its isuocc, also requirs thc spplicmt for such pamit to file a signcd statmmt that he or dE b licoscd pmuut to thc provisiore of thc Contractor's Licensed [:w (Chapt6 9. Comncncing with Setion 7000 of Division 3 of thc Busincs adr Profsions Codc) or that hc or slre is oempt thqefrom ud thc basis for the allcgcd cxmption. Any violation of Scrion ?031.5 by ey applicmt for a pnnit subjets thc applicmt to a civil penalty ofnot more thil live hundrcd dollm ($500). -1. as owner ofthe property, or my employecs with rvages as their sole conrpensation. willdo the work and the stnrcture b not intended or offered for sale (Sec.7M4. Business and Professions Code: The Contractor's Licensc Law does not apply to an owner of the propo'ty who builds or improves theron. and who does such work himself or herself or through his or her own employees. provided that such impovanrcnts are not intendod or offered for sale. l[, hower/er. the building or improvement is sold within one ]rzr of complaion. the Ourner Buildcr will have the burden of proving thd he or she did not build or improve the propot'y for the purpose of sale). -f , as owner of the property. arn exclusively contracting with licensed contractors to construct the project (Sec. 7U4, Buiness and hofession Code: The Contractor's License Law does not apply to an orvner of property who builds or improves thereon, and rvho contracts for such projects with a Contracto(s) licensed pursuant to the Conlractor's License Law). -l am exernpt under Section-. B. & P.C. for this reason. Date: Owner: WORKERS' COMPENSATION DECLARATION I hereby affinn under penalty of perjury one of the following declarations: _l have and will maintain a Certificate of Consent to Self-lnsure for workers' conrpensation, as provided for by Section 3700 of the Labor Code. for the performance of the work for which the permit is issued. _l have and rvill maintain 3700 of the Labor Code. for the performance of rvork for rvhich this and policy number are: E,v tryc4^y z t- ZotJ(o,,.,6ooo t zqtlr 1- -l cerrify that in the performance of the work for w'hich this perrnit is issued. I shall not onploy any person in any manner so as to become subject to the rvork€rs'compensation laws of California and agree that if I should become subje<t to the norkers' compensation provisions of SEction 3700 of the Labor Code. I shall. forthwith comply rvith those provisions. WARNING: Failure to secure workers' compensation coverage civil fines up to one hundred thousand dollars ($100.000). in is unlawful. and shall subject an ernployer to criminal panalties and the cost of compensation. damages as provided for the Section -3076 of the Labor Code, interest and attorney's I DECI { RATION I hereby aflirrn under penalty of perjury that I am licensed under provision of Chapter 9 (commencing with Section 7000) of Division 3 of the lllusiness and Professions Code, and my license is in full force atd eflect. \y'..*"C-Number:L5 ( W I hcreby affm undo p€nalty of perjury thar thac is a construcliotr knding agqcy for the pqfomce of the work for *'hich this pqnh b isued (Se. 3097. Civ. C.). Lender's Name: Lender's Address: APPLICANT NT'CI ^ RATION I herety affrrm under penalty of perjury one of the follorving declarations: Dernolition Perrnits-Asbestos Notification Federal Regulations (Title 40. Part6) -Required Letter of Notification ,r'cefli$/ that the federal regulations regarding asbestos removalare not applicable to this project. is con'ect. I agree to cornply rvith all City and County reprcsentatives of this City and County to entet' upon the above mentioned prope(y fcrr (ppli.",,t or Agent ,€Iermitee nnme 14 I )I Set Backs Forms/Steel/Holdowns -z/t-l -lv--1 Erection Pads 7'"/ry ',T.A-{U UFER Ground SLAB Floor Su bfloor/VenUI n su lation Roof Sheathinq Shear Wa!! Framing lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif ,I FINAL 3 /lo/aD <ry#ry-'.;n Certificate of Occupancy 7 ru Notes, Remarks, Etc. x \n,., (t \otl 8 ,