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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I h6eby aflim und6 poalty of perjury that I m cxmpt ftom thc Coriltaclos' Licre law for thc following r@n (Sc.7031.5 Busins md Prcfeion Codc): Any City or County $'hich rcquirs a po'mit to construct. alts. improvq donolish or rcpair uy structuq prior to its isumcc, also requirs thc applicmt for such pcmit to lilc . sigocd stdmot that hc or shc b licas{d plBet to thc provisioE of thc Contrrctor's Licoscd law (Chapt6 9. Commcncing with S6tion 7000 of Division -l of the BBins aod prcf6ioN Codc) or that hc or shc is ompt thqefrom md thc basis for thc allcgcd cxmption. Any violation of Sccrion 7031.5 by any applicantforapmitsubjctsthc applicanttoacivilpâ‚¬naltyofnotmorethufivchundrcddollas($500). __1, I om6 of thc propcrty. or my cmployc with wag6 a thcir mlc ompcmtion. will do thc wolt atd thc structuc is not intmded or olfcred for slc (Se,7044, Busin6s md Prcfcssiom Codq 'I hc Conlraclor's Lictre Law do6 not spply to o oMa of thc popoly who huilds or imprcu th@n. ed who do6 such wrk himsclf or hmelf or thrcugh his or hc om cmployc. providcd that such improvffits rc not intodcd orofH for slc. lf. howo(. thc building or improvmot is sld within onc )ar ofsmpldio]l the Owno Buikkr will havc thc budq ofproving tha hc or shc dlJ not hriH or imprcrc the prcpqty for thc pupos of ule). _1. u ornq of the propqty. m cxclusively contracting sith licffcd conlracloB to coGtruct the proj{t (Sa. 7044. BEinE ud Proftssim Code: Thc ContBctor's Licosc Law do6 not apply to u ownc ofpropa'ly who builds or improv6 ths@n. and who otrtnds for such projds wirh a Contnclo(s) licqEcd puBwt to thc Contraclor's Licffi [rw) -l an excmpt undq Sstion---, B. & P.C. for lhis rcen, Il.rI n.()n lter:lra!tt' I hereby affirrn under penalty of perjury one of the follorving __-l have and will maintain a Certificate of Consent to Self-lnsure for workers' cornpensation. as provided for by Section -3700 of the l-abor Code, for the performance of the work for which the permit is issued. _t have and will maintain workers' compensation insurance. as required by Section 3700 of the Labor Code, for the po'fonnance of the work for which this pennit is issued. My workers' compensation insurance catrier and policy numhr are: ,*x,, \Zrrfch hrWr;foX CnSVtahcA LO poricy *,^*,2 u)LS5tT-|SIO5 Expires:t --l certify that in the perforrnance of the work for which this perrnit is stl as to become subject to the workers'cotnpensation laws of Califcrrnia. issued. I shall not employ any person in any lnanner antl that if I should becotne subject to the rvorkers' compensation provisions of Section 3700 of the those provisions. WARNING: Failure to secure rvorkers' compensation and employer to criminal penalties and civil hnes up lo one hundred thousand dollars of compensation. damages as Section 3076 of the Labor Code. interest and I)ate:ll4-rq I of Chapter 9 (comrnencing with Section 7000) of Division 3I hereby affirm under penalty of perjury that I am of the Business and Professions Code. and my is in full force and effect. .%qKE I hereby affrrm under penalty of pcrjury that there a lending agency for the perfonnance of the work for rvhich this permil is issued (Sec. 3097. Civ. C.). Lcnder's Name: Lender's Address: APPLICANT DEC LARATION I herclry affrnn under penalty of perjury one of the follorving declarat ions: Demolition Permits-Asbestos Notification Federal Regulations ('Iitle 40. Parl6) -Required Letter of Notification _l certifu that the federal regulations regarding asbestos removal are not applicable to this project. I certi$ that I have read this and state that the above inftrnnation Ls corre'ct. I agree to comply rvith all City and County ordinances and State Larvs relating to and hereby authorize representatives of this City and County to errter upon the above mentioned property for Applicnnt or Agent l'crnritee n:une (print): Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloo r/Ve nt/l n s u I atio n Roof Sheathins Shear Wall Framincr lnsulation/Enerqy Drvwall Ext./lnt. Lath Brown Coat J\Iasonrv Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif. lr FINAL t1,ha l(,Dffr'')64 Wtrl Certificate of Occupancy lt tl Notes. Remarks, Etc. lo.70 lq - fhftatYt I t'License r ro,,, --[ ) l-lAZ'-CL) """, ll -? 47 >+/n(4t_F fl I I