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BUILDING. INSPEGTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I heeby allirm undq pcnalty of perjury that I m excmpt from the Contrsctoc' Licose Lau' for thc following rNn (S6.70-t 1.5 Busincs and Profsion Codc): Any City or County rvhich require a pcmil to construct. alt6. improvc. doolish or rcpair my strucluq prior to its isuilcc. also rcquic thc applicant for such pcmit to lile a signcd statmot thal hc or she b licmscd puEuilt to the prcvisions of tlE Contraclor's Licosâ‚¬d Law (Chapts 9. Commcncing u'ith Sction 7000 of Division I of thc Busincs ild Prcfesions Codc) or that he or shc is exmpl thqcftom md thc basis for thc allegcd exmption. Any violation of Sarion 70-11.5 by any applicant for a pcrmil subjets the applicmt to a civil poalty ofnot more thm five hundrcd dollm ($500). _1. as owner of the propc'rty. or my employeâ‚¬s with wages as their sole compensation. rvilldo the rvork and the structure is not intendgJ or offered for sale (Sec.7044. tsusiness and hofessions Code: The Contractor's License Law does not apply to an owner of the property rvho builds or improves thereon. and who does such wort hirnself or herself or through his or her own employees. provided that such improvanents are not intended or offered for sale. l[. horvever. the btrilding or improvement is sold within onc year of cornplaion. the Orvner Builder rvill have the burden of proving that he or she did not build or improve the propo'ty for the purpose of sale). ---1. as owner of the propoty. arn exclusively contracting witlr liccnsetl contlactors lo constnrct the project (Sec. 7044. Business and hofiession Code: I'he Contractor's License Larv does not apply to an owner of propcrty who builds or improves thereon. and rvho contracls for such projects rvith a Contractor(s) licensed pursuant to the Contractor's License Larv). -lalnexenlptunderSection-.B.&P.C.forthisreason. I)atc: On'ner: WORKERS' CONT PENSATION DECLARAI'ION I hereby affrrrn under penalty of perjury one of the follorving declarations: _l have and rvill rnaintain a Certificate of Consent to Self-lnsure for u'orkers' compensation. as provided for by Settion 3700 of the labor Code. for the performance of the work for which the petmit is issued. _l have and rvill rnaintain workers' compensation insurance. as required by Section -1700 of the Labor Code. for the pa'formance of the rvork for which this permit is issued. My rvorkers' compensation insurance carrier and policy number are: Can'ier: Policy Nurnber:_Expires: ___l cerlify that in the performance of the work for which this perrnit is issued. I shall not ernploy any person in any manner so as to become subiect to the rvorkers' compensation laws of California. zurd agree that if I should become subject to the rvorkers' compensation provisions of Section -3700 of the Labor Code. I shall. forthrvith comply rvith those provisions. ., WARNING: Failure to secure u'orkers' cornpensation coverage is unlarvful. and shall subiect an anployer to criminal penalties antl civil fines up to one hundred thousand dollars ($100.000). in addition to the cost of compensation. darnages as provided for the Section -1076 of the l-abor Code. interest and attorney's fees. Dete: Applicant: LICENSED CONTRACTOR DECI.ARATION I hereby affinn under penalty of perjury that I am licenscd under provision of Chapter 9 (cornmencing with Section 7000) of Division 3 of the Business and Profcssions Code. and my licerrse is in full force and effect. License ('lass: Date: License Nunrber: _ (lonlractor: CONS-I'RUC1'ION LENDING ACENCY I hreby affirrn under fmatty of perjury that thqc is a construclion len<Iing agency for the pofonnmce of the work for which this lmnit is j5sued (Sec. 3097. Civ. C.). TLender's Narne:/ Lender's Address: APPLICANT DECLARA'I'ION I hereby affinn under penalty of perjury one of the follorving de<larations: Dernolition Perrnits-Asbestos Notification Federal Regulations (Titlc 40. Pafl6) _Required Letter of Notilication _l certify that the federal regulations regarding asbestos removal are not applicable to this project. -l ccrtify thal t havc rad this application ild statcthat thc above infomation is corccl. I agrc to comply with all City and County ordinancB and State Laws rclaing to building construction, ffd hcrcby authorizc reprMtativc of this City md Couoty to @tq qnn tlrc abovc mcntioncd prcperty for inspstion purpos6. Appllcrtrt or Agst SiSnslurc:_ Ihlc:_ I'ernt ilcc niunt, (prirrt ): Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloor/Venul nsu Iation Roof Sheathins Shear Wall Framing ll- 8-|o,iEg,J lcri lnsulation/Energy n DOnruall l,n \ Lath l-1241 b'lll"t EI-wn Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif. , FINAL 7 Certificate of Notes Remarks Etc. : Aldvob ?ol/(D / ,'r I t\I A a ce '1r'd . /i I I / I t.tf'w\v '/\ ) a-