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BUILDING. INSPECTOR RECORD !a SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DEI,CARA1ION I hoeby alfirm undo panalty of Jn'jury that I fln excmpt ftom the Contrac'to6' Licere lrw for lhc following reen (5(.7031.5 Businss ud Profession Code): Any City or County which requirc a pernit lo costruct. alt6. improvq demolish or repair my structuâ‚¬. prior to its isumce. also requirB thc applicot for such pennit to file a signcd statmot that hc or shc b licdEâ‚¬d pmuet to lhe provisions of the Contmctor's Licensed Law (Chaptq 9. Commencing with S(tion 7000 of Division 3 ofthe Busine od ProfcsionsCode)orthatheorshcisex.mptthacliommdthcbasisforthcallcgcdcxmption. AnyviolslionofSrcrionT03l.5byany applicant for a pqmit subjrcts thc applicant to a civil penahy of not more thu livc hundrcd dollas ($500). - --1. as o\r'ner of the propâ‚¬rty. or my employees with rvages as their sole compensation. willdo the rvork and the structure is not intended or offered for sale (Sec.7044. Business and Professions Code: 'fhe Contractor's License Law does not apply to an orvner of the proper'ly w'ho builds or improves thermn. and u'ho does such work hirnself or herself or through his or her orvn employees. provided that such improvetnetts are not intended or offercrJ for sale. lf. hos'ever. the building or improvetnent is sold rvithin one year of cornpletion. the Orvner Builder rvill have the burden of proving that he or she did not build or improve the properry for the purpose of sale). -1. as o\.!'ner of the propeny. arn exclusively contracting with licensed contraclors to construct the poject (Sec. 7U4. Business and Proftssion Code: The Contraclor's License Larv does not apply to an owner of property rvho builds or improves thâ‚¬reon. and wlto contracts for such projects with a Contracto(s) licensed pursuant to the Contractor's License Law). -l am exempt under Section-. B. & P.C. for this reason. Dnte'__ Owner:_ WORKERS' COMPENSATION DECLARATION I hereby alTirm under penalty of perjury one of the following declarations: --.1 have and will maintain a Cerrificate of Consent to Self-lnsure for workers' cornpensation. as provided for by Section 3700 of the Labor Code. for the performance of the work for which the pernrit is issued. -l have and s'ill maintain rvorkers' compensation insurance. as required by Section 3700 of the labor Code. for the performance of the work for rvhich this pennit is issued. My workcrs' compensation insurance can'ier and policy number are: c*,i*,-' ,kY\( r ;<qr\ > U y';c|., tr-:- ot\lI /Lc -l certify that in the perfonnance of the work for which this permit is issued. I shall not employ any person in any manner so as to become subject to the rvorkers' compensation larvs of California. and agree that if I should become subject to tlre workers' compensation provisions of Section 3700 of the Labor Code. I shall. forthrvith comply rvith those provisions. WARNING: Failure to secure workers' compensation coverage is unlawful. and shall subject an ernployer to criminal penalties and civil {ines up to one hundred thousand dollars ($100.000). in addition to the cost of compensation. darnages as provided fcrr the Section 3076 [-abor interest and attornq,'s fees. tc (a I hereby affirm under penalty of perjury that I am licensed Chapter 9 (commencing w'ith Section 7000) ofpivision -j of the Business and Professions Code. and rny license is in full force and effect. LicenseCturr' ' ( /o ,q)i)-Q l q contracto ,Dare: t | ) ---T-_ q. CONSTRUCTION LENDING AGEN(]Y I hercby aflirm undo pcralty ofpsjury that lhse is a coBtructiod lmding agmcy for the pedonnance ofthe rvork for uhich this Ismit is issued (Sec. 3097. Civ. C.). l.ender's Name: Lender's Address: _ APPLICANT DECLARATION I hot{ry affinn under penalty of perjury one of the follorving declarations: Dcmolition Permits-Asbestos Notification Federal Regulations (I'itle 40. Pafl6) _ _Rec;uired Letterof Notification -l certify that the federal regulations regarding asbestos renroval are not applicable to this project. !M certify that I have read this application and state thar the above infonnation is correct. t agree to cornply ordinances and State Laws relating to building construction. and hereby authorize representatives of this City u'ith all City and County and County to enter upon the ffi::H:il"i: permitee nnnre (prinr):f, -@n LCI-Ua4aL -Dere,.lf/7lq Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloor/Venul ns u lation Roof Sheathinq Shear Wall Framing lnsulation/Energy Dryruall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif /t I \ FINAL /',/tti /ztl ,-)*7 / Certificate of Qccupancy /,\J -..) <t a -2