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BUILD!NG. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hereby allirrn undr poahy of psjury that I m exempt fiom lhc Contraclos' Licmse l.aw for thc follorving rcmn (Sc.7031.5 Busin6s aod Prof6ion Codc): Any City or Coutrty which reluirs a po'rnit to coNrruct. alt6, improve. donolish or rcpair afry structuq prior lo its isumcq alrc rcquirB the applicilt for such pmit to file a signei stalmf,t that hâ‚¬ or she b licflsed puEuilt to the previsions of the Contractor's Licensd Law (Chapter 9. Commencing with Sslion 7000 of Division J of thc Busins and Prcfe$ions (:ode) or that he or she is cxcmpt lheefrom and the basis for thc alleged cxernptiotr. Any violation ofsc{tion 703 1.5 by an).i applicant for s pcnnit subjcts thâ‚¬ applicant to a civil pcnalty ofnot more lhil five hundted dolhs ($500). _1. as owner of the property. or my employeâ‚¬s with wages as their sole compensation. n'illdo the rvork and the structure is not intende<l or offered for sale (Sec.7044. Business and Professions Code: ]'he Contractor's l.icense Larv does not apply to an osner of the propary rvho builds or improves thereon. and s'ho does such $'ork himself or herself or through his or her ou'n employees. provided that such improvements are not intended oroffâ‚¬red for sale. l[. horvever. the building or improvement is sold within one ]'ear of completion. the Owner Builder will have the burden of proving that he or she did not build or improve the propoty for the purpose of sale). _1. as owner of the property. am exclusively contracting rvith licensed contractors to conslruct the proiect (Sec. 7M4. Business and hoftssion Code: The Contraclor's l-icense Larv does not apply to an owner of propc'rty u'ho builds or improves thereon. and rvho contracts for such projects rvith a Contracto(s) licensed pursuant to the Contractor's License Law). -l arn excmpt under Section-. B. & P.C. for this reason. I)aIt:( )n lrer': lVORKERS' CONI PENSATION DECLARA'TION I hereby affinn uncler penalty of perjury one of the follorving declarations: -l have and will maintain a Certificate of Consent to Self-lnsure for rvorkers' compersation. as provided for by Section -j700 of the Labor Code. for the performance of the work for which the pennit is issued. -l have and rvill maintain workers' compensation insurance. as required by Section .1700 of the Labor Code, for the performance of the u'hich this is issued. [vS rvorkers' I Policy -l certify that in the perfornrance of the w'ork for which this pernrit is issued. I shall not ernploy any person in any manner so as to become subject to the rvorkers' compersation las's of California. and agree lhat if I should become subject to the rvorkers' compensation provisions of Section 3700 of the Labnr Code. I shall. forthw'ith cornply rvith those provisions. WARNIN(): I;ailure to secure rvorkers' compensation coverage is unlarv[ul. and shall subject an ernployer to crirninal gr,malties and civil fines up to one hundred thousand dollars ($100.000). in the cost of conrpensation. darnages as provided for the Scction of the Code. interest ancl attorney's fees. I hereby affirm under penalty of perjury that I am licensed under of the Business and Professions Codc. and my license is in full 9 (conrrnencing rvith Section 7000) of Division 3 License Dnte: a,,orr-BlW ('ontractor,^ I hereby affrrm under penalty of perjury that there is a construction lending agency issued (Sec. .1097. Civ. C.). Lender's Nanre: perfonnance of the work for rvhich this p,ermit is Lender's Adct'ess: APPLICANT DECLARATION I ltoeby aflimr under penalty of perjury one of the following declarations: Dernolition Permits-Asbestos Notification Federal Regulations (T'itle 40. Pan6) -.Required Letter of Notification _l cerlify that the federal regulations regarding asbestos rernovalare not applicable to this project. _l certify that I have read this application that thc atxrve infonnation is correct. I agree to conrply u'ith all City and ('ounty ordinances and State Las's relating to building hereby authoriz.e representatives of this City and County to enter upon the above mentioned property for Applicaut or Agent I'erlrritee ,rr",lL ta'\q Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/Ve nUl n s u latio n Roof Sheathinq Shear Wall Framing lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif. I FINAL I /r I ?j2 Dk (t0e \*84 Certificate of Occupancy Notes, Remarks, Etc. lZT ] 1_CT