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BUILDING- INSPECTOR RECORD SITE.WORK DATE !D/SIG.COMMENTS OWNER BUTLDER DELCARATION I hocby affm unrlo pcralty of pcrjury that I m cr.mpt ftom thc ConiracloE' Licce law for the following rcen [ie.7031.5 Busines md Profcsion Codc): Any City or County which rcquirc a pcmh to coGtruct, altc, improvg dcrnolish or EpaL uy : struciuc, lrior to its issuucc. also requirc thc appliclt for such pctrnit to filc a signcd $d@61 thd hc or shc b licqEcd ptmilt ' ro the prcvisioru of thc Contmctor's Liccnscd Law (Chapts 9, Comcncing with Sdtion 7000 of Division 3 of the Bsins md Prcfsions Cod€) or thal hc or shc fu €x@pt thqcfrom ad the basis for the allcged amption. Any violation of Scction 7031.5 by any applicmr for a mit subjets thc ap,plicant to a civil poalty of nol morc tha fivc hundrcd dollm ($500). --1. as owner of the propcrty, or my employc€s with wages as their sole compensation. will do the work and the structurc is not intended or offered for sale (Sec.7044. Business and hofiessions Code: The Contractor's License law does not apply to an owner of the property who builds or improves thereon. and who does such wo* himself or herself or through his or her own employees. provided that such improvcrnants are not intended or offcred for sale. l[, howarer. the building or improvement is sold within one ]rcar of completion. the O'rvner Buildcr will have the hrden of proving tha he or she did not build or improve the property for the purpose of sale). _1, as owner of the propcrty. arn exclusively contracting with licensed contractors to construct the projcct (Sec. 7M4, Business and hof€ssion Code: The Contractor's l,icense Law does not apply to an owncr of property who builds or improves thereon, and who contracts for such projects with a Contracto(s) licorsed pursuant to the Contractor's License taw). -l arn excmpt under Scction-. B. & P.C. tor this reason. Dnte:__ yaBsEEs:caMPJNStUlO! DECI.ASAIION I h@by aItrm undq pcnalty of pojury one of thc following delaratiore: _l have.nd will maintain a Cqtifrcatc ofcoMt to Selflmurc for rcrkc' rcmpcrudion, a povidcd for by Setion 3700 of thc labor Codc, for the pqfomcc of thc wort for which the pqmit b isucd. ! -lr6avc and will msif,tain work6' compcroation ireurrec, c rcquired by setion 3700 of thc tabor Codc, for thc pcfomue of thd work for which this pcrmit is issucd My workc' composation ireuficc cmi6 a[d policy nubc rc: fi yr^e. ficcnvt ?L ,tal( L Policy z _i certi$ that in the pcrformance of the work for which this perrnit is issued. I shall not ernploy any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the labor Code. I shall. forthwith comply with those provisions. \ WARNING: Failure to secure workers' compensation coverage is unlawful. and shall subjo;t an onploycr to criminal penahics and civil fines up to one hundred thousand dollars ($100.000). Scction 3076 of the Labor Code. interest and attorney's fees. in addition to the cost of compensation. damages as provided for the ) orrc,'Z -4 - ? o'l c-- I hereby affinn under penalty of perjury that I arn licenscd (comrnencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Licensecr"r* C( b LicenseNumber:Ct7 7t orr".'7-\-?u?o contracror, ViVlnlSolq,r. CONSTRUCTION LEIIDING AGENCY I hmby amm unds pcoalty of perjury that thqc is a coNtruclion loding agmcy for thc pafomce of the work for which this pqmit b isucd (S(. 3097, Civ. C.). knds's Nmc: - Lender's Ad&ess:l APPLICANT DECLARATION I haeby affirm under penalty of perjury one of the foilowing declarations: Demolition Permits-Asbcstos Notification Federal Regulations (Title 40. Pat16) --Required lrtter of Notification t -l cstiry that thc fcdqal rcXulatiore regading obctos rmoval ue not applicablc to this prcjel. IL:l cdiry thal I havc rod this application ild statc that thc abovc hfomtion is cor€1. I aBrc to comply with all City md County ordhmcG ud State trws rclating to building construcliotr atd hqeby authorizc rcprGatativB of this City ud Couty to 6tG upon thc above me'ntioned property for inspection purposes. Pernritec nnme L9 orrc,7- 4- ? oZ o Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloor/VenUl nsu Iation Roof Sheathinq Shear Wall Framing Insulation/Enerqy Drwval! Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputv Final Report Enqineer Final Report Flood Zone Certif \n^ FINAL t\n\ua /t\0061 ,TTYI Certificate of Occupancy \\\[ Notes, Remarks, Etc. Applicrnt or Agent Signature:_ 4 r?q.5 t