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BUILDING. INSPECTOR RECORD (}F COMMENTSSITE.WORK DATE ID/SIG OWNERBUILDERDELCARATION , I haeby affrm undc pmalty of perjury that I m erempt frcm thc Contraclom' Lic6s lrw for rhc following rcmn (SG,7031.5 Buins mC Prcfesion Code): Any City or County which rcquire a po'mit to condrucl, alto. improvc, &molish or rcpair ay structuc, prior to its i$uecc, also require the applicmt for such permit to filc a signcd slarmmt thd hc or drc b licosed pmuilt to thc provisions of thc Contrsctor's Liccns€d [:w (Chaptc 9, Commcncing with Setiotr 7000 of Division 3 of the Buincs ud Profcsions Code) or that hc or shc is cxmpt thacfrom ed the basis for thc allcXcd cxmption. Any violation of S61ion 7031.5 by any applicantforapmitsubjctsthe applicanttoacivilpcnaltyofnolmorcthafivchundrcddollus($500). _1. as owner of the property. or my employees with wages as their sole compensalion. willdo the work and thc structure is not intended or offered for sale (Sec.7044. Business and Professions Code: The Contractor's License Larv does not apply to an owner of the property rvho builds or improves thereon. and who does such work hirnself or herself or through his or her own employees. provided rhat such improvernents are not intended or ofFered for sale. l[, however. the building or improvement is sold within one year of cornplction, the Orvner Builder will have the burden of proving that he or shc did not build or improve the propo'ty for the purpose of sale). _1. as owner of the propeny, am exclusively contracting with licensed contractors to construct the project (Sec. 7U4, Business arld Prof€ssion Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and rvho contracts for such projects with a Contracto(s) licensed pursuant to the Contractor's License Law). -l am exempt under Section--. B. & P.C. for this reason. _ Owner: WORKERS' COMPENSATION DECLARATION I hereby affirrn under penalty of pcrjury one of the following declarations: _l have and will maintain a Certlfrcate of Consent to Self-lnsure for workers' compensation, as providcd for by Section 3700 of thc Labor Code, for the performance of the work for rvhich the po'rnit is issued. _l have and Scction 3700 of the Labor Code. for the pcrformance of rcarier and policy numh are: ,\ the work for Policy \Zr) _l certify that in the performance of the work for which this permit is issued. I shall not onploy any person in arry manner so as to becorne subject to the rvorkers' compensation laws of California. and agrec that if I should become subject to the rvorkers' compensation provisions of Section 3700 of the Labor Code. I shall. forthwith comply rvith those provisions. WARNING: Failure to secure workers' compensation coverage is unlawful. and shall subjcct an onployer to oiminal pena!.les and civil fines up to one hundred thousand dollars ($100.000). in addition to the cost of compensation, damages as provided for the Section -3076 of the Labor Code. interest and fees. Cr.fDale:tuntlT-l I hereby affrm under penalty of perjury that I arn licensed under provision of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code. and my license is in full force and effect. \ License Date: Nurntrr: t-r tql tr "l \ \v l ,I W I hercby aflirm undq pcf,alty of pcrjury that thae is I construction lcndhg ogmcy for thc p6fomucc of thc work for which this psmit is issucd (Se. 3097. Civ. C.). Lender's Nante: I-cnder's Address: APPLICANT DECLAITATTON I hertbyaffinnunder penalty of perjury one of the following dcclarations: Demolition Permits-Asbestos Notification Federal Regulations (Title 40, Part6) -Required Letter of Notification ,fiS that the federal regulations regarding asbcstos rernoval are not applicable to this project. O-tc€rtiry that I have read this application and state that the above information is correct. I agree to comply with all City and County theordinances and State laws relating to building and hereby authoriz.e representativcs of this City and County to enter upon above rnentioned propefly for Applicnnt or Agent Perlnilec nArnc rL ontel \L Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/VenUI nsu lation Roof Sheathing Shear Wall Framinq lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req. Deputy Final Report Enqineer Final Report Flood Zone Certif I FINAL L+\M 7a)?&rMst *6 Certificate of Occupancy 't It Notes,. Remarks, Etc. 7 o ,/W I I T o rzah- SzaG t-, I I^rc 7 o &,rl t 76t (a a I I \c,tt b q. Lr5 I v q lt I