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BUILD!NG. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenU! nsu I ation Roof Sheathing 74.1 4.Er-r ISZ Shear Wall Framing lnsu lation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif . FINAL l-lo-/r'-8 lo> Certificate of Occupancy Notes, Remarks, Etc. OWNER BUILDI'R DELCARAI'ION I hereby affirm untler penalty of perjury that I am exempt from the Contractors' License Law ftrr the following reason (Sec.7O-11.5 Business and Profession Co'de): Any City or County which requires a Jrrmit to construct. alter, improve. dermlish <lr repair any structure, prirr to its issuance, also requires the applicant frrr such perrnit to file a signed statement that he or she is licensed pursuant to the pnrvisions of the Contractor's Licensed Law (Chapter 9. Commencing with .Section 7(XX) of Division -j of the Business antl Professions Cotle) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violatkrn of Section 703 L5 by any applicant for a Jrcrmit suhjects the applicant to a civil penalty of not nxrre than five huntlred dollars ($5(X)). _1, as owner of the prcpeny. or my empkryees with wages as their srle comJrcnsation, will do the work and the struclurc is not intended orofferedforsale(Sec.TO44.BusinessandProfessionsClode:TheContract()r'sl,icenseLawdoesnotapplytoanownerof the property wtxr builds rlr improves thereon, and wtxl drrcs such work himself or herself or through his or her own empkryees. provided that such improvenrnts are not intended oroffrred for sale. If. hrwever. the btrilding or inqrnrvenrnt is sold within one )rear of cornpletion. the Owner Buikler will have the burden of proving that he or she dil not build or irnprole the proJrerty for the purprse of sah). -1, asownerof the property. amexclusivelycontracting with licensetl contractorsto construct the pnr.iect (Sec. 7044, Business and hofersilnCotle:TheContractor'sLicenseLawdoesnotapplytoanownerofpropertywhohuildsorimprovesthereon, and who c()nlracts filr such prnjects with a C()ntracto(s) licensed pursuant to the Contractor's License Law). _l am exempt under B. & P.C. frrr this reason. Date:_Oryner: WORKI.' RS' COMPENSAI'ION DECLARATION I hereby affirm under penalty of perjury one of the ftrllowing declarations: _l haveandwill maintainaCertilrcateofConsenttoSelf-lnsureforworkers'conrpensation.as pnrviderlforbySection3T([ofthe Latxlr Crlde, for the performance of the work for which the permit is issuetl. _l have and will maintain hy Section -17(X) of the Lahor Code. for the Jrerformance of carrier and plicy number are:the work frrr this ) r Policy _l certify that in the performance of lhe work frrr which this permit is issuetl. I shall not empkry any person in any rnanner so ilsto hecorne suh.iect to the workers'comp€nsation laws of California. and agree that if I shrukl beconrc sub.iect tothe wrlrkers' cotnpens:rtion WARNING: Failure to prtrvisions of Section 37(X) of the l.ahrr Code, I shall. frrrthwith comply with those provisions. secure wrlrkers'compensati()n c()verilge tkrllars ($ l(X).(XX)). in is unlawful. and shall an employer to civil fines up to ()ne hundred thousand adtlition to the as provitletl frrr thc Section 3O76 of the Lahrr Code. interest antl attorney's fees. ,r,.", lAftTf /? DE,CI.ARAI'ION I herehy affirm untler penalty of perjury that I aln licensed under provision of Chapter 9 (comnrncing with Section 7UX)) of Division of the Business and Professions Code. and my license is in full ftrrce arxl effect. ,l License Date:_ c36 Nulnber: Contractor: CONS'I'RUCTION LI'NDING AGENCY I herehy affirm untler penalty of Jrrjury that there is a construction hnding agency frrr the performance of the work for which this permit is issued (Sec. 3097. Civ. C.). L.ender's Name: Lentler's Address: AI'I'LICAN'I' DE,CLARA'I'I ON I hereby affirm under penalty of perjury one of the following tleclarations: Demolition Permits-Ashestos Notification Federal Regulations (Title 40, Part6) _Required Letter of Notification _l certify that the federalregulations regarding asheslos rerxlvalare not applicnhle to this _l certify that I have read this application and state that the ordinances antl Stlte [.aws relating to huilding atxrve mentioned proflerty for inspection Applicant or Agent SifnatuT6:- Iternritee name (print ): __-w- crlrrect.I agree 0B-07-201 5 a 1- all City and County uJxrn the q