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BUILDING- INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER II I.'ILDI:R DIiI,CA RATION I hcreby afFrnr under penalty of perjury that I anr exenrpt from the Contractors' License l-aw for the following rcason (Sec.7031.5 liusiness and Prolbssion Code): Any City or County which requires a permit lo construct, aller, irnprove, dernolish or repair any structure, prior to its issuance. also requires thc applicant tbr such permit to file a signed slatemenl that hc or she is licenscd pursuanl lo lhc provisions o[ the Contractor's l-icensed taw (Chapter 9. Commencing with .Section 70fi) of Division 3 ol'the Business and Prot'essions Code) or that he or she ls exempt therefrom and the ba.sis fbr tlrc alleged exemption. Any violation of Section 703 1.5 by any applicant for a permit subjects thc applicanl to a civil pcnalty of not morc than fivc hundred dollars ($5tXt1. _1. as owncr ol'the propcrty. or my employees with wagcs as their sole compcnsation, will do thc work and the stnrcture is rnt interxlctl or offered for sale (Scc.70+a, Business and Pmfcssions Culc: Thc Contraclor's Liccnse Law tloes not apply lo an owner of the property who builds or improves thereon and who does such work himself or herself or through ltis or her own employees, provided that such improvenrnts are rnl intended orollered for salc. Il. howcver. ttrc buiHing or inprovenrcnt Ls soH within orc )€ar of conphtiol, the Owner Buildcr will luve thc burden of proving that he or shc did not build or impnove the propcrty for the purpose of ta:tc\i,/ ."-[ as owncr of the properly, am exclusively contructing with licensed conlraclors to conslruct the project (Scc. 7044. Business arxl Prrotbsskn Code: The Contractor's License Law does not apply to an owner of property who builds or improves thercon. and who conlracrs for such projccts with a Contractor(s) licenscd pursuant lo the Contractor's License kw). _l am exempt P.C, tbr I hcrcby atlirm undcr penalty of pcrjury onc of the lbllowing _l have and will maintain a Certificate of Consent to Self-lnsure for workers' compensation, as pruvided for by Section 3700 of the Labor Codc. for the Jrcrformance of the work lbr which thc Jrcrmit is Lssued. _l have and will maintain workers' compen-sation insurance, as recluired by Section 3700 of the l-abor Code, for the performance of thc work tbr which this pcrmit is issued. My workers' compcnsation insurancc carricr and Snlicy number are: Policy _l ccrtify that in thc pcrformancc of thc work for which this Jrcrmit is issuetl, I shall not employ any person in any manner so as lo bccome subjcct to thc workers' conrpensation laws of California, and agrcc that if I should become subject to thc workers' c<lmlrcnsation provisions of Section 3700 of the Labor Cotle, I shal!, forthwith comply with thosc provisions. t WARNING: Failurc to sccure workers'compensation covcrdge is unlawful, antl shall subject an employer to criminal Jrcnaltics antl compensation, damages ls provided for thecivil fines up to one thousand dollars ion to the Section 3076 of the interest and ?) I,ICENSED CONTRA(IT0R I)T]CLARATION r liccnscd undcr provision ol Chaptl:r liccnsc' is in hrll ftrrcc anrl clll'ct. I hcreby al'lirm undcr penalty of pcrjury that I arn of thc Business and Profcssions Code, and my 9 (cornrnencing with Scctkrn 7fin) ol'l)ivision 3 Liccnse Class: Licensc Nutnber: - CONSTRI.'C.TION I,[.:NDI NG AG T:NCY I hercby atlirm under penalty of 5rcrjury that lhere is a constnrction lending agency ftrr the performance of the work lbr which this permit is issucd (.Sec. 1097, Civ. C.). Lender's Nanre: I-ender's Address: APPLICANT DECLARATION I hercby affrnt under penalty of perjury one of the following declarations: Dcm<llition Permits-Asbestos Notification Federal Regulations (Title 40, Part6) -Required lrtter of Notification this project. with all City and County of this Applicant or Agcnt Permitee nanle and lo enler uPon the Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf Ioor/VenVl n su !ation Roof Sheathinq Shear Wall Framinq lnsulation/Enerqv Drvwall Ext./lnt. Lath Brown Coat [Masonry Pool Fence T-Bar Handicap Req Deputv Final Report Enqineer Final Report Flood Zone Certif . FINAL 'Ut'/'z)lZc 7<N {t4> Zq Certificate of Notes, Remarks, Etc. Rev. 08-07-2015