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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS 0\\'NF,R Ilt rIl,l)1..R l)F.1,(',tRA'l l()N I hseby affirm unds pâ‚¬nalty of pqjury that I m exmpt frem the ContracloE' Licarc lrw for thc following rcen (56.70-11.5- Buinss and Profsion Code): Any City or County which rcquira a pannit to construct. altc. improvc dcmolish or rcpair my structuq prior to its issumcq also requir6 the applicmt for such lmit to file a signed stdmot that he or she b licqscd pmuilt to thc prcvisions of the Contractor's Licenred Larv (Chapter 9. Commencing with Setion 7000 of Division 3 of the Busines md Prefe$ionsCodelorthathcorsheiscxcmptthGefromedthebasisfortheallegedexemption. AoyviolationofSdionT03l.5byany applicantforapmitsubjctsthe applicsnttoacivilpenaltyofnotmorethmfivehundrcddollm($500). ' _1. as owner of the Fnoperty. or my employers with rvages as their sole compensation. rvilldo the rvork and the structure is not intended or offered for sale (Sec.7044. Business and hofessions Code: 'I'he Contraclor's [-icense [.aw does not apply to an o\lner of the property rvho builds or irnproves therqrn. and who does such wort himself or herself or through his or her own employees. provided that such irnprovonents are not intended or offerd for sale. tf, however. the building or itnprovement is sold within one year of completion. the Orvner Builder rvill have the burden of proving that he or she did not build or irnprove the propoty for the purpose o[ sale). -1. as owner of the property. am exclusively contracting rvith licensed contractors to constnrct the project (Sec. 7044. Buiness and [tofession Code: I'he Contractor's License Lau'does not apply to an owner of property rvho builds or improves thereon. and rvho contracts for such projects rvith a Contracto(s) licensed pursuant to the Contractor's License Larv). -l am exempt under Section-. B. & P.C. for this reason. Date: Owner: WORKF'RS' CONI PENSATION DECLARATION I hereby affrnn under penalty of perjury one of the follow'ing declarations: _l have and rvill maintain a Certificate of Consent to Self-lnsure for rvorkers' compensation. as provided for by Section 3700 of the Labor Code. for the perfionnance of the rvork for rvhich the petmit is issued. -l have and rvill rnaintain workers' cotnpensation insurance. as by Section 3700 of the Labor Code. for the performance of the rvork for is workers'carrier and plicy number are: .D Policy *rrb"r, - ClO Lf t t_.a Exoires:z/z r, _l ceflify that in the performance of the rvork fiur rvhich this perrnit is issued. I shall not employ any person in any manner so asto bec1rme subject to the workers'cornpensation larvs of California. and agree that if I should becorne subject to the rvorkef,s' compensation provisions of Se'ction .1700 of the Labor Code. I shall. forrhrvith cornply rvith those provisions. WARNTNG: [;ailure to sâ‚¬cure ttorkers' civil fines up lo one hundred thousand compensation coverage is unlas'ful. and shall subject an onployer to criminal penalties and compensation. damages as provided for thedollarsincost of Section -1076 of the Code. interest and attorney's / DECT.ARATION I hereby affirm un<ler penalty of perjury that t arn licensed under provision of Chapter 9 (cornmencing with Section 7000) of Qivision 3 of the Business and Professions Code. and my license is in full force and effect. o License Class: I ,rnu)l[ffi a Number: W I hrcby affim unda pcnalty of pcrjury that th@ is 8 construc(ion lcnding agocy for thc pcfomcc of thc work for which this pqmit b issued (Se. 3097, Civ. C.). Lender's Name: _ Lender's Address: APPLTCANT DECLARATION I h6dry allinn under penalty of perjury onc of the following declarations: Dernolition Perrnits-Asbestos Notification Federal Regulations (Title 40. Part6) -Required Letter of Notification colify that thc federalregulations regzu'ding asbestos rcrnovalare not applicable to this project. certi$/ that I have read and state that the ahrve inflormation is correct. I agree to cornply rvith all City and County ordinances and Slate l-au's building and hereby authorize represextatives of this City and County to enter upon the above mentioned property for Ap;llicarrt or Agcrtt l'ernritee nunre (grrirrt): F AAf h-( O ,Ly-- orr"rl'ftn(q Set Backs Forms/Steel/Holdowns Ereqtion Pdds UFER Ground SLAB FIoor Su bfloor/VenUI nsu lation I ^/l ^A Roof Sheathing ////1/q /(Wtecz vaw Shear Wall I Framing Insulation/Enerqy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputv Final Report Engineer Final Report Flood Zone Certif A f.^,,(.r. nA FINAL ///lv/{4 /-rutz /cv_q Certificate of Occupancy Notes, Remarks, Etc. &7Lfr