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SITE.WORK DATE !D/SIG.COMMENTS OWNER BUILDER DEI,CARA'I'ION <br />I herehy affirm untler penatty of Jrcrjury that I am exempt fnrm the Contractors' License Law for the following reason (.Sec.70.l1.5 <br />Business and Profession Cule): Any City or County which requires a Jrrmit to construcl. alter, improve, derntlish or repair any <br />structure. prkrr to its issuance. also requires the applicant for such permit to llle a signed staternent that he or she is licensetl pursuanl <br />Io the pnrvisions of the Contractor's Licensed Law (Chapter 9. Commencing with .Section 7(XD of Division 3 of the Business and <br />Pr6fessi6nsCode)orthatheorsheisexempttherefromandthehasisfrrrtheallegedexernption. AnyviolationofSectionT0.ll.5hyany <br />applicant for a permit subjects the applicant to a civil penalty of not rxtre than five hundred dollars ($5U)). <br />_t. as owner of the pn)frerty. or my empkryees with wages as their sole ctlmpensati()n, will do tlr wrlrk and the struclure is not <br />inrendetl 6rgfferetlforsale(Sec.TO44.BusinessandProfessionsCode: 'fheCirntractor'sl-icenseLawdoesnotapplytoanownerof <br />the pr()perty whl buikls or impmves thereon. and whr does such work himself or herself rtr through his or her own empkryees. <br />prrlvitletl that such impr<lvernents are not intentletl ur offered for sale. lf. however. the truiltling or improvenrcnt is srlld within one ytar <br />of completit)n, rhe Owner BuiUer witlhave the burden of proving that he or she ditl not huiklor improve the pnlperty forthe purprseof <br />sale). <br />_t. asowner rrf the property, amexctusively contracting with licensetl contract()rst() c()nstruct the pnr.iect (Sec. 7()44. Business <br />arul Pnrfessirn Code: The Contractor's l-icense Law does not apply to an owner of proJrerty who builds tlr imprtrves thereon, <br />and whrr contracts for such pnrjects with a Contracto(s) licensetl pursuant to the Contractor's License Law). <br />-l <br />amexempt under .Section-, B. & P.C. for this reason. <br />l):rlt. ( )rr lrt.r <br />*ar**r*t' coMPUNSA't'l0N <br />DECLARA'I'ION <br />I herehy affirrn under penalty of per.iury one of the frrllowing declaralions: <br />_l have and will maintain a Certifrcate of Consent to .Self- Insure for workers' comlrcnsation, as provided for by Section -17(X) of the <br />l-ahrr Cule. firr the grcrformance of the work firr which the permit is issued. <br />_l have and wilt maintain workers'compensation insurance. as required hy Section 37(X) of the Labor Code. for the yrrftrrmance of <br />the work for which this permit is issued. My workers' comp€nsation insurance carrier arxl Jxrlicy number are: <br />4M1/q <br />_l certify that in the performance of the wrrrk frrr which this permit is issuetl, I shall not <br />s() asto beconre suhject trr the workers'compensltion laws of California, and agree that if I <br />/''2\\ I I <br />ernpkry any person id any m#tner <br />should hecome subject to the <br />workers' compensation provisions of .Section .17(X) of the l:rtnr Code. I shall. ftrrthwith comply with those provisions. <br />WARNTN(): Failure to secure workers' compensation coverage <br />civil fines up to one hundred thrtusand tkrllars ($l(X).(XX)), in <br />IS shall suh.iect an employer to criminal penalties and <br />atltl it ion of compensation. damages ns provided for the <br />lo76 Lahrr interest antl attorney's fees. <br />I <br />I herehy affirm under penalty of per.iury that I am licensetl under 9 (comntncing with Section 7firu) of Divisirtn 3 <br />of the Business and Professions C}rde. aml my license is in full firrce antl effect. <br />q\v1 u9 <br />I hercby affirm under Srenalty of prjury that there is a construction <br />issued (Sec. 3O97, Civ. C.). <br />aSency perfirrntance of the work for *'hich this permit is <br />l.entler's Atldress: <br />A I'I'LICAN'I DECLAR A'T'I ON <br />I hereby affirm untler penalty of perjury one of the ftrllowing declarations: <br />Demolition Permits-Asbestos Notification F:etleral Regulations (Title 40, Part6) <br />-Required <br />Letter of Notification <br />_l certify that the federalregulations regarding ashestos removalare not applicahle trl this project. <br />-l <br />certify that I have read this application antl state that atnve information is correct. I agree to comply with all City and County <br />onlinances and State Laws relating to building herehy auth)riz.e representatives of this City and County ttr enter ufx)n lhe <br />:rhrve nrntioned property for <br />ul shApplicant or Agent I)ale: <br />T T <br />a 114 <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenVI nsu lation - l -Jl.t2- <br />Roof Sheathinq \Y-lb7 <br />Shear Wall { <br />Framinq I l<cz <br />lnsu latio nlEnerqv )-2a. ;9 (?cz <br />Drvwall <br />Ext./lnt. Lath lt\- <br />Brown Coat \dl <br />Masonry a <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enoineer Final Reoort <br />Flood Zone Certif <br />I I A-t lrt <br />FINAL h 7 a)Prh0/l er -H67 <br />Certificate of Occu <br />Notes, Remarks, Etc. <br />F <br />,/ <br />ol <br />BUILDING- INSPECTOR RECORD T <br />f:{ev. 0B-07-201 5 <br />a <br />/ <br />) <br />-/ <br />Y <br />\ermitee name f printl, 1t0 Prl ls/