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SITE.WORK DATE ID/SIG.COMMENTS OWNIiR BU I I,DIiR DICI,CA RATION I hcreby affirm under penalty of perjury that I am exempt from the Contractos' Licensc [:w for the following reason (Scc.7031.5 Busincss and Profcssion Code): Any City or County which requires a pcrmit to conslruct, aher. irnprove, demolish or rcpair any structure. prior to its issuance. also rcquires the applicant tbr such permit to file a signed staternent that lre or she is licensed pursuant to lhe pnrvi.sions of thc Contractor's l.icensed t:w (Chaptcr 9. Commencing with Section 70fi) ol'Division 3 ot'the Busines:a:! Prot'essions Code) or that he or she is exempt therefrom and the basis tbr the alleged cxemption. Any violation of Section 7031 .5 by any applicant for a permit subjects thc applicant to a civil penalty of not rnore than live hundred dollars ($5m1. D& "* owncr of the propcrty, or rny ernptoyees with wages as their sole compcnsation, willdo the work and the stnrcrure is rnt interxlcd or ofTered for salc (Sec.7(Xn, Business and Professions Cotle: The Contractor's Licensc l-aw docs not apply to an owner of the property who builds or improves thereou and wtrl does such work hirnself or herself or through his or her own employees, provided that such improvernnts are not intended or olfered lor salc. Il, howevc'r, the building or improvenrcnt is sold wilhin one year of completion, thc Owncr Builder will have the burden of proving that he or she tlid not build or improve thc property for tlre purposc of sale). _1. as owner of thc property, am exclusively contracting with licensed conlraclors to conslruct the pnrject (Sec. 7044, Business arrd PnllbssirxrCode: TheContractor'sLicerrseLawdoesnotopplytoanownerofpropertywhobuildsorimprovesthereon. and who conlracts for such pro.iccts with a Contractor(s) licen.scd Contractor's Licensc taw). _l anr exempt B.&P ooL Z6 I hcreby aflirm under penalty of perjury one of the tbllowing declarations: _I have and will nraintain a Certilicatc of Consent to Selt'-lnsure for workers' comper$ation, as pnrvided for by Section 3700 of the Lahor Codc. for the Jrcrformance of thc work for which thc permit is lssued. _l have and will maintain workers' conlpersation insurance, as required hy Section 3700 of the Labor Code, fbr lhe pcrfornurnce of thc work filr which this pcrmit is issuc'd. My workcrs' compcnsation insurancc carricr arxl Jrolicy numbcr are: Policy Number: Expircs: { t ccrrlty that in thc prlbrmance of tlrc work for which this prmit is issucd, I shall not cmploy any pcrson in any manner (o iTtn bcconre subjcct to the workers' comlrcnsation laws of Califonria. and agrcc that if I should beconrc subject to thc workers' .urnp"nruiion provisions of Section 3700 of the Labor Cotle, I shall, forthwith conrply with ttrosc provisions. WARNING: Failurc to sccure workcrs'compensation coverdgc is unlawful. and shall subjcct an employer to criminal pcnaltics and civil fines up to one hundred thousand dollars (Sl(X).(XX)). in lo the of damage.s as providc{for the ISection 3076 of the [:tnr Code, inlerest and attorrrcy's fees. ,r^r".' 0z I zoIznuo I hcreby allirrn undcr grcnalty of pcrjury that I am liccnsed undcr Chapter 9 (cornrncncing with Section 7ffn) of Dirision 3 of the Business and Protbssions Codc, and my liccnsc is in full lirrcc aml clfcct. Licensc Class: Liccnsc Numbcr: l)ate: CONSTRI.'CTION I,I.]NDI NG AGT.]NCY I hereby allrrnr under penalty of per.iury that there is a constructirxr lenrling agency for the performarn-:e of the work tirr which this pernrit Ls issued (Sec. 3097. Civ. C.). [-cnder's Namc: l-endcr's Address: APPLICANT DECLARATION I trreby affrnr under pcnalty of pcrjury one of the following doclarations: Demolition Permits-Asbestos Notification Federal Regulations (Title 40, Part6) _Required [-etter of Notification _[ certify that the federal regulations regarding asbestos removal are not applicable to this project. dd."niry that I have rcatl this apptication arxl state the above informalion is correcl. I agree to comply with all City and County ordinances arrd State Laws relating to building autlxrrize rcpresenlativcs of thi.s City and County to enter uF)n the atxrvc mcntioncd prof&.^rty frlr inspcction Applicant or Agcnt Permitee nanle o,,,, Oz [z 6 f zo zu, Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bf loor/Ve nUI nsu latio n Roof Sheathino Shear Wall Framing Insulation/Eneroy Drywall Ext./lnt. Lath Brown Coat Nlasonry Pool Fence T-Bar Handicap Req. Deputy Final Report Enqineer Final Report Flood Zone Certif t/It /4, FINAL 5//0/iry/v iln?/w,1 /ffi/ Certificate of Occupancv I I Notes, Remarks, Etc. \ s BUILDING. INSPECTOR RECORD Rev. 0B-07-2015