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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG COMMENTS olvN I..R lt U I l.l)FlR I)l.ll,CA RA'l'lON fScc.7o.1l.5I hcrchy atlirnr undcr Jrcnalty <lf Jrcrjury that I am cxempt liom the Contractors' Licensc Law litr thc lirllowing Gason Busincss and Protbssion Ctrlc): Any City or County which rcquircs a Jrcrmil k) conslrucl. altcr. improvc. dcmolish or rclair,ay structurc, ITi)r to ils issuancc, also rcquircs thc applicant lbr such Jtrmit kr lilc a signcd statcmnl lhat hc or shc is liccnrcd pmuanl to thc fovisions of thc Contractor's Liccnrcd law (Chaplcr 9. Commcncin8 wilh Scction 7m0 of Division J of the Business and Prclbssions Code) or thtt hc or shc is cxcmpt thcrclhrm and thc basis tirr thc allcgcd cxcnption. Any vblati(rn ofScction 70J I 5 by any applicant for a pcmit suhjccts lhc applicanl k) a civil pcnalty (rf nol morc lhan fivc hundred dollars (S5U)). _1, as ()wncr of thc propcrty, or nly cmployees with wagcs as their solc compcnsation, will do thc work and the structurc is nrtt intcnrlcrl or 6tl'crerl titr sale (Sec.70rl4, Business and Profcssions C<xlc: The Contractor's Licensc Law docs not apply lo an owncr of thc pn)pcrty wlxr builds or impntvcs thcrcrln, and wtrr docs such work himself <lr hcrsclf or lhrough his or hcr own cmployees, providcd that such improvcrncnts are not intcndcd or otTercd lirr sale. ltl howevcr, thc building or impnrvcrncnt is sold within onc ycar of complctign, thc Owpcr BuiUer will havc thc burdcn ol'proving that he rlr shc did not buikl or improvc thc propcrty firr the purJxrsc of sale). _1, as owncr ol'the proJrcrty, am cxclusivcly contracting with liccnscd contraclttrs lo conslrucl thc prcjcct (Sec. J0dd, $usingss arxl Pnltbssign Codc: Thc Contractor's Liccnse Law does nol apply lo an owncr of pnrJrcrty who builds or improvcs thereon. and who contracts lirr such pnljccts with a Contractor(s) liccnscd pursuant lo thc Contractor's Licensc Law). -l am cxcmpt under Section-, B. & P.C. tilr this rcason. I)alc: WORKERS' CONIPENSATION DECLARATION I hcrcby all'irnt undcr pcnalty of pcrjury onc of thc tirlklwing dcclarations: _l havc arxt will maintain a Ccrtiticatc of Conscnt to Sclt'-lnsure tbr workcrs' comJrcnsation, as prcvidcd lirr by Scction 3700 of thc Labor Codc, lirr the perlbrmancc of the work fbr which thc pcrmit Ls issued. _l havc antl will maintain workcrs' compcnsation insurancc, as rcquircd hy Scction -1700 of thc l.abor Crxle, tirr the pcrftrrmance of the work lbr which this prmit is issued. My workcrs' compcnsation insurance carrier and prlicy number iuc: Policy Numbcr: ExPircs: _l ccrtity that in thc Jrcrtbrmancc of thc work tilr which this Jrcrmit is issucd, I shall not employ any lrcrson in any manncr so as lo bccomc subjcct to the workcrs' comJrcnsation laws ol'Califilrnia, and agrcc that if I should hccomc suhjcct to lhe wrlrkcrs' compcnsation provisions of Scction J7fi) of the Latxlr Ctxlc, I shall, titrthwith comply with thosc provisitlns. WARNING: Failurc to sccurc workers' contJrcnsation covcrage is unlawtul, and shall subjcct an cmpktycr to criminal pcnaltics and civil t'incs up to onc hunrJred thousand dollars ($lm,m0), in addition to lhc cost of compensalion, damagcs as providctl ftlr thc Scction -1076 ot'the Lahtr CuJc, intcrest and attonrcy's lbcs. I)alc: LICENSED CONTRACTOR DECLARATION I hcrcby a1irnr under pcnalty of pcrjury that I am licenscd undcr provision of Chapler 9 (commcncing with Scction 7m0) of Division -J of thc Busincss and Prol'cssi<lns Codc, anl my liccnse is in tull forcc anl ct'l'cct. CONSTRUCTION LENDING AGENCY I hcrcby affrm unrlcr Fnaltyof Frjury lhat thsc is a construcllrn hnding aScncy tbr lhc fErformnce of lhc work lbr which this lrmil is issucrl (Scc. 1097, Civ. C.). [.cntler's Namc: APPLICANT DECLARATION I hcrcby allirm under Jrcnalty of pcrjury onc tlf thc lirllowing declaralions: Dcmolition Permits-Ashestos Notification Fedcral Rcgulations (Titlc 40, Part6) -Rcqu ircrl l.et ter of Notiticat irln -l certili thal thc fcdcEt rcSulatioN rcganling asbcsk)s rcm)val rc not apPlicablc k, this Prujcct. _l â‚¬rtily thdr I have rcad this application axt statc thar thc at$ve inlomlion is corect. I a8re lo @mply with all Cityand County ordinaets md Sttle Laws rclating to builling construclion. ard hcrchy authorizc rclrcsntatives ofthis City and Counly lo cntet uF)n thc abovc mntioncd pDJpny for insFction purlx)es. Applicant or Agenl Set Backs Forms/Steel/Holdowns *n Erection Pads UFER Ground SLAB Floor Su bf loor/VenVl nsu lation Roof Sheathinq Shear Wall Framing lnsu lation/Enerqy Drywall Ext./lnt. Lath Brown Coat I\/asonry Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif L FINAL I Nl7/))v $r ',&fl, 5ra * lollbarLto Certificate of Occupancy ,rl Re Etc. lo t- 7 I lt tt lSllq