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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcrcby aftirm undcr lEnally of Fr.iury that I m crcmpt fR,m tlE ConlracloF' Li(nrc Law li)r thc fotlowirg rcaen (Se.to.tl.5 Busincss arl Profcssion Cole): Any City or Counly which rcquircs a lEmil to conslruct. altcr. improvc, dcfrrlish or rcpair any structurc. pri(rr to its issuancc, alro rcquircs thc lpplicant for such ltmit to filc a si8ncd slalcrent that lE or shc is liccn$d pursuet to thc pn visions of thc Contractor's Licensd kw (Chaptcr 9, Commcreing wilh Scclion 7000 of Division 3 of thc Busincss and Prulessions Cqlc) or lhat hc or shc is erempt lhscfiom and thc basis f(rr thc allcScd cxcmption. Any violation of Scctitn ?01 I .5 by any applicant for a lrrmil subjets thc applicsnt lo a civil pcnally of not morc than fivc hundrcd dolles (5500). _1, as owncr of'thc propcrly, or my cmpbyecs with wagcs as thcir sole compcnsation, will do thc work and thc stru,cture is not intendcd gr gffcrcd tirr salc (Sc.,c.7044, Busincss and Prol'cssions Crxlc: Thc Contractor's Licensc [-aw rJoes not apply to an owner of thc pn)pcrty wlxr builds or inrpnrvcs thercrrn, arxl wtxr docs such work himsclf or hcrsclf or thK)uEIh his or hcr own empkryecs. providcd tlrat such irnprtverncnts arc not intcnded rlrofi'cred lirr salc. Il, howevcr, thc building or improvcrncnt is sold wilhin onc ycar of complction, thc Owner Builder will havc thc burdcn of pnrving that hc or shc did rxrt buikl or improve thc pnrpcfy tirr thc purposc of sah). _1, as owncr of thc property, am exclusively conlracting with liccnsed contraclors to construct thc projcct (Scc. JOdd, f,usingss arxl hotession Codc: The Contractor's Liccnse Law docs not apply to an owner o[ propcrty who builds or improves thercon, and who contracts for such projccts with a Contractor(s) licenscd pursuant ltt thc Contractor's License Law). -Iamcxemr,tundcrScctittn-'B.&P.C.lilrthisrcason.l)ale: }VORKERS' COTIT PENSATION DECLARATTON I hcrcby atTirm under Jrcnalty of prjury one of the lillkrwing dcclarations: _lhavcanrlwillmaintainaCcrtiticatcofConscnttoSclt-lnsurctilrworkcrs'conrJrcnsalion,as providcdtbrbyScctirtnJT00ofthc Labor Crxlc. lbr the pcrtilrmancc of the work filr which the Jrcrmit is issuetl. _l havc antl will maintain workcrs' compensation insurancc. as rcquircrl hy Seclion 17fi) of lhe Labor Code, lbr the Jrcrlilrmancc of the work ftrr which this permit is issucd. My workcrs' compensalion insurance carrier anl pllicy numtrcr iue: Policy Numbcr: ExPircs: _l ccrrify that in thc pcrtilrmance of thc work lilr which this;rcrmit is issuctl, I shall not empltly any lrcrson in any manncr so as to bccomc subjcct to thc workers' com;rcnsation laws of Calilirrnia, and agrec that if I should bcctlme suhjcct to thc t workcrs' compensation provisions of Section 17fi) of the L-ahrr Crxlc. I shall. tilrthwith comply with thttse provisions. WARNING: Failurc to secure workcrs' compensation covera€rc is unlawful. and shall suhjcct an employcr to criminal Jrcnaltics'and civil tincs up to onc hundrcd thousand rlollars ($l(n,UX)), in atldition to thc cost of compensation, damages as provitlcd ti,r thc Section 1076 of the l-abor Ctxle, intcresl and attorney's fccs. r, I lda^. LICENSED CONTRACTOR DECLARATION I hcreby aftrm undcr pcnalty of pcrjury that I am liccnscd undcr pnrvision of Chapter 9 (cummcncing with Section 7000) of Division 3 of the Business and Pntfbssions Code, and my licensc is in l'ull tirrce and ctl'cct. Liccnse Class: License Numbcr: CONSTRUCTION LENDING AGENCY I hcrcby affirm undcr Jrcnalty of lErjury that thm is a onstructirn lcndhg agcncy for thc JErf(rrmrec of thc wrrk lirr which this JEmit is issucd (Se. 309?, Civ. C.). lrntler's Namc: l,enrlcr's Addrcss: APPLICANT DECLARATION I lrcreby atlirm untlcr penalty of 1^*rjury one of the lblklwing dcclarations: Demolition Permits-Asbcstos Notification Fcderal Rcgulations (f itlc 40, Part6) -Rcquircd l-cttcr of Nolitication _t ccrtiti that thc t'cdcral regulations rcgarding asbcslos removalarc not applicablc to this projcct. _l ccrtity that I havc rcad this application altd slale that thc with all City and County and County to enter uJnn thcordinanccs and Statc [-aws rclating to atxrvc mcntioncd prolrcrty tbr Applicant or Agent l)cnnilee n$nrc Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenVl nsu latio n Roof Sheathinq Shear Wal! Framinq lnsu lation/Enerqy Drywall Ext./lnt. Lath Brown Coat Jt/asonrv Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif . It FINAL Ststu llrrnp ')++x7 Certificate of Occupancy l Notes, Remarks, Etc. *ri l-?')o