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BUILDING- INSPECTOR RECORD SITE.WORK DATE !D/SIG.COMMENTS OWNI.]R II I.' I I,T)T'R DI.:I,CA RATION I hereby affirm under penalty of perjury that I am exempt from the Contractors' License law for thc following reason (Sec'.7031.5 Business and Prol'ession Codc): Any City or County which rcquircs a permit lo conslruct, altcr. improve, demolish or repair any stntcture, prior to its issuance. also requires the applicant for such pernrit to file a signed slatemenl that he or she is licensed pursuant to the provisions of ttr. Conlractor's l.iccnsed taw (Chapter 9. Commcncing with Scction 7fiX) ol'Division 3 of the Busincss and Prof'essions Code) or that he or she is exempt therefiom and tlrc basis lbr the alleged exemption. Any violation of Section 7031 .5 by any applicant for a pcnnit subjects the npplicant to a civil penllty o[ not more than five hundred dollars ($500). Za'. ^t owner of thc proflcnv. or rny ernptoyees with wagcs as their sole compcnsation. witldo the work ard the shrcture is not irrtentletl or offeretl for salc (Sec'.7(X4. Business and Pnrlessions Cule: The Contractor's License l-aw docs not apply to an owncr of the prugrerty who builds or improrrts thcreon, and whcr does such work himself or herself or through his or her own employees, provided that such irnprovcrrcnts are not intended or ollertd [or salc. Il. hnwever, thc building or inprovennnt is sold within one year of conrpletkrn, thc Owner Buikler will have the burtlen of proving that hc or she did not buikl or improvc Ore property for the purporc of sah). _1. as owner of the properly, am exclusively contracting with licensetl contraclors to conslrucl thc pnrject (Scc. 7044. Business and Protbssion Code: The Contractor's License Law does not apply to an owner of property who builds or improves there<ut. antl who contracts for such pro.iccts with a Contractor(s) liccnscd pursuanl to thc Conlraclor's License Law). -l am excmpt under B. & P.C.this rrate, ,:-itvlll<, I hcreby alf irm under Jrcnalty of perjury one of the tbllowing _l have and will maintain a Certificate of Consent to Selt'-lnsure for workers' comprcnsation, as provided for by Section 3700 of the Lahor Code, for the pcrformancc of thc work for which the permit is issued. _l have and will maintain workers' compensation insurancc, as required by Seclion 3700 of the krbor Code, for the perfornunce of thc work tbr which this Jrcrmit is issued. My workers' comJrcnsation insurancc carricr ancl policy numhcr are: Carrier: Policv Numbcr: E,xoires: -l ccrriff thar in thc perfirrmancc of the work for which this prmit is issuetl, I shall not employ any person in any manner so as to bcconre subjcct to thc workers' compensation laws of California. and agree that if I stnuld bccome subject to the . workers' compensation provisions of Section 3700 of the Labor Code, I shall, forthwith comply with tlrosc provisions. WARNING: Failure to secure workers'compensation coverage ls unlawful, and shall subjcct an employer to criminal grcnalties and civil ftnes up to one hundred thousand dollars ($l00,UX)). in adtlition cost of conrpensation, damages as providcd for the Seclion 3076 of the Lahrr Code, inlerest and l"l '7.,{) I hercby allirm undcr pcnalty of Jrcrjury that I arn licenricd 9 (cornrncncing with Section 7000) of Division 3 of thc Business and Profcssions Codc, and my license is in full forcc arxl elfcct. Liccnsc Class: Liccnse Numbcr: CONSTRI,'CTION I,I.:NI)TNG AGENCY I hercby athrm under Jrenalty of perjury that there is a constructiorr lending agerrcy for the Jrcrformance of the work tbr which this Srerntit is issucd (.Scc. 3097, Civ. C.). [-cnder's Name: lcnder's Address: APPLICANT DECLARATION I hcrcby affirm under penalty of perjury one of the following declarations: f)entolition Permits-Asbestos Notification Federal Regulations (Title 40, Part6) _Required l-etter of Notification _l certity that thc federal regulations regarding asbestos rcnpval are not applicable to lhis pmix't.7r ,Yl*ify that I travc rcad this application arxl stare that thc abovc information is correc't. I agrec to comply with all City and County and County to enter upon lheordinances and State Laws relating construct iorr, anJ herehy authorizc representatives atxlvc mcntioncd property for Applicunt or Agcnt l'rnrritee nanle purposcs. L of this City (1 U) Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenVl nsu lation I Roof Sheathinq 7- 2llolo \0 Shear Wall Framino lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat Nlasonry Pool Fence T-Bar Handicap Req Deoutv Final Report Enqineer Final Report Flood Zone Certif I rl ;1 FINAL n r)\ 1n )hr v6t trrt Certificate of Occupancv I I Notes, Remarks, Etc. Rev. 08-07-2015 .l Contractori