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BUILDING. !NSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hseby amm unds penalty of pojury that I m qmpt film the Coilraclo6 Licmre law for thc following rcen (58.7031.5 Businss and Profsion Code): Any City or Coumy which rcquira a pmit to comrud. allq. improvq dernolish or rcpair my structure. prior to its isumcc, also rcquirG the applicant for such pmit lo file a signed statcmqt that hc or shc islicffcd psuant to the provisions of the Contmtor's Licensed Law (Chapter 9. Commencing wilh Sstion 7000 of Division 3 of the Busin6s atd Prcfe$ions Codc) or that he or she is umpt thsefrom ild the basis for the allege<l excmption. Any violation of Scaion ?031.5 tf, any applicant for a pemit subjsts thc applicilt to a civil penalty ofnot more lhil fivc hundred dollm ($500). _1. as o\\,nef, of the property. or my employees with wages as their sole compensation. willdo the rvork and the structurc is not intended or offered for sale (Sec.7044. Busines and hofessions Code: The Contraclor's License Law does not apply to an owner of the property who builds or improves thereon. and rvho does such wort himself or herself or through his or her orvn employees. pr ovided that such irnprovanents arc not intended or offered for sale. If. horvever'. lhe building or improvente'nt is sold within one year of completion. the Orvner Builder will have the burden of proving that he or she did not build or improve the propoty for the purpose of sale). _1. as owncr of the prop€rty. am exclusively contracting s'ith licensed contraclors lo construct the project (Sec. 7M4. Business and Profession Code: The Contractor's License Larv does not apply to an o$,ner of property rvho builds or improves theretn. and rvho contracts for such projeds with a Contracto(s) licensed pursuant to the Contractor's License Larv). I an exernpt under Section- . Il. & P.C. for this reason. I)atc:( )rvner: WORKERS' CONT PENSA'TION DECLARATION I hereby affirm under penalty of po'jury one of the follou'ing declaratiors: ._l have and will tnaintain a Certillcate of Consent to Self-lnsure for workers' compensation. as provided ftrr by Section 3700 of the Labor Code, for the perfonnance of the rvork for which the pcrmit is issued. _l have and will rnaintain rvorkers' compensation insurance. as required by Settion -1700 of the Labor Code. for the perfonnance of the u'ork for which this permit is issued. My workers' cornpq$ation insurance carrier and policy number are: Carricr: t)1riic1 Ntrntbct : lrrPil g5' _l cerrify that in the perforrnance of the rvork for rvhich this perrnit is issued. I shall in any rnanncr so as to ber'orne subject to the u'orkets' compensation larvs of California. and agree that if to the rvotters' cornpersation provisions of Section 3700 of the l.abor Code. I shall. forths'ith WARNIN(): Failure to secure rvorkers' compensation coveraBe is unlas'[ul. and shall to crirninal panalties and civil fines up to one hundred thousand dollars ($100.000). in addition to the cost of as provided for the Section 3076 Code. intcrest and attorney's fees. 1 DECLARATION I hcreby alllrm under penalty of perjury that I arn licensed under provision of ('rvith Scction 7000) of l)ivision .l l.icerrsc ('lass:License Nurnber: [)ate:0//Contrtctot, L (]ONS'I'RUC'[ION I,ENDI N(; AG I.:N('\' I heeby aflirm undo penaty of psjury thst th@ is a congructiori lending agmcy for thc pqfomilce of lhc work for rvhich this pqmit is issued (Sec. 3097. Civ. C.). Lender's Narne: APPLICANT DECLARA'TION I horry aflinn under penalty of pcrjury one of the follorving dc.clarations: Dernolition Permits-Asbestos Notification Federal Regulations (Title 40. Part6) -Required Lelter of Notification -l cerrily that the federalregulations regarding not applicable to this project. _l cedify that I have read this application and ordinances and State [au's relating to building above rnentioned property for inspection Applicant or Agent Signature: S Pernritee nrme (print):_ purposes. Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/Ve nUl n s u !atio n 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. -/r^ FINAL 4t'{b 1 M Certificate of Occu Notes, Remarks, Etc. \\ brr- of thc Business and Professions Code. and my licen-se is in full force and effec't. Lcnrlcr''s Adrlrcss: