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SITE.WORK DATE !D/SIG.COMMENTS OWNER BUILDER DEI,CARA'I'ION I herehy affirm untler penatty of Jrcrjury that I am exempt fnrm the Contractors' License Law for the following reason (.Sec.70.l1.5 Business and Profession Cule): Any City or County which requires a Jrrmit to construcl. alter, improve, derntlish or repair any structure. prkrr to its issuance. also requires the applicant for such permit to llle a signed staternent that he or she is licensetl pursuanl Io the pnrvisions of the Contractor's Licensed Law (Chapter 9. Commencing with .Section 7(XD of Division 3 of the Business and Pr6fessi6nsCode)orthatheorsheisexempttherefromandthehasisfrrrtheallegedexernption. AnyviolationofSectionT0.ll.5hyany applicant for a permit subjects the applicant to a civil penalty of not rxtre than five hundred dollars ($5U)). _t. as owner of the pn)frerty. or my empkryees with wages as their sole ctlmpensati()n, will do tlr wrlrk and the struclure is not inrendetl 6rgfferetlforsale(Sec.TO44.BusinessandProfessionsCode: 'fheCirntractor'sl-icenseLawdoesnotapplytoanownerof the pr()perty whl buikls or impmves thereon. and whr does such work himself or herself rtr through his or her own empkryees. prrlvitletl that such impr<lvernents are not intentletl ur offered for sale. lf. however. the truiltling or improvenrcnt is srlld within one ytar of completit)n, rhe Owner BuiUer witlhave the burden of proving that he or she ditl not huiklor improve the pnlperty forthe purprseof sale). _t. asowner rrf the property, amexctusively contracting with licensetl contract()rst() c()nstruct the pnr.iect (Sec. 7()44. Business arul Pnrfessirn Code: The Contractor's l-icense Law does not apply to an owner of proJrerty who builds tlr imprtrves thereon, and whrr contracts for such pnrjects with a Contracto(s) licensetl pursuant to the Contractor's License Law). -l amexempt under .Section-, B. & P.C. for this reason. l):rlt. ( )rr lrt.r *ar**r*t' coMPUNSA't'l0N DECLARA'I'ION I herehy affirrn under penalty of per.iury one of the frrllowing declaralions: _l have and will maintain a Certifrcate of Consent to .Self- Insure for workers' comlrcnsation, as provided for by Section -17(X) of the l-ahrr Cule. firr the grcrformance of the work firr which the permit is issued. _l have and wilt maintain workers'compensation insurance. as required hy Section 37(X) of the Labor Code. for the yrrftrrmance of the work for which this permit is issued. My workers' comp€nsation insurance carrier arxl Jxrlicy number are: 4M1/q _l certify that in the performance of the wrrrk frrr which this permit is issuetl, I shall not s() asto beconre suhject trr the workers'compensltion laws of California, and agree that if I /''2\\ I I ernpkry any person id any m#tner should hecome subject to the workers' compensation provisions of .Section .17(X) of the l:rtnr Code. I shall. ftrrthwith comply with those provisions. WARNTN(): Failure to secure workers' compensation coverage civil fines up to one hundred thrtusand tkrllars ($l(X).(XX)), in IS shall suh.iect an employer to criminal penalties and atltl it ion of compensation. damages ns provided for the lo76 Lahrr interest antl attorney's fees. I I herehy affirm under penalty of per.iury that I am licensetl under 9 (comntncing with Section 7firu) of Divisirtn 3 of the Business and Professions C}rde. aml my license is in full firrce antl effect. q\v1 u9 I hercby affirm under Srenalty of prjury that there is a construction issued (Sec. 3O97, Civ. C.). aSency perfirrntance of the work for *'hich this permit is l.entler's Atldress: A I'I'LICAN'I DECLAR A'T'I ON I hereby affirm untler penalty of perjury one of the ftrllowing declarations: Demolition Permits-Asbestos Notification F:etleral Regulations (Title 40, Part6) -Required Letter of Notification _l certify that the federalregulations regarding ashestos removalare not applicahle trl this project. -l certify that I have read this application antl state that atnve information is correct. I agree to comply with all City and County onlinances and State Laws relating to building herehy auth)riz.e representatives of this City and County ttr enter ufx)n lhe :rhrve nrntioned property for ul shApplicant or Agent I)ale: T T a 114 Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenVI nsu lation - l -Jl.t2- Roof Sheathinq \Y-lb7 Shear Wall { Framinq I l<cz lnsu latio nlEnerqv )-2a. ;9 (?cz Drvwall Ext./lnt. Lath lt\- Brown Coat \dl Masonry a Pool Fence T-Bar Handicap Req Deputy Final Report Enoineer Final Reoort Flood Zone Certif I I A-t lrt FINAL h 7 a)Prh0/l er -H67 Certificate of Occu Notes, Remarks, Etc. F ,/ ol BUILDING- INSPECTOR RECORD T f:{ev. 0B-07-201 5 a / ) -/ Y \ermitee name f printl, 1t0 Prl ls/