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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hereby aflim undcr pqalty of pqjury that I m cxcmpt frcm lhc Contraclom' l.icos law for thc following rcmn (56.7031.5 Ilusinss ad Profmion Codc): Any City or County which requirs a pemit to construct, alto, improvc. danolish or rcpair ay structurc. prior to its issuuce. also rcquirc thc applicut for such pcrmil to file a siBncd statmfit that hc or she b licmsâ‚¬d pmuilt to the prcvisions of lhe Contractor's l-iccnscd larv (('hapls 9. Commencing u ilh Sstion 7000 of Division I of thc Busines ild Pmfesions Code) or that he or shc is dcmpt thqcfrom od the basis for thc alleged cxmption. Any violation of Setion 7031.5 by any applicant for a pmit subjats thc applicant to a civil peoalty of not morc thil five hundred dollas ($500). _ I. as owner of the property. or my employees with wages as their sole cornpensation. w'illdo the rvork and the struclure is not intcnded or offered for sale (Sec.7044. Business and Professions Code: '[he Contraclor's l-icense l,aw'does nol apply to an orvner of the properly s'ho builds or improves thermn. and s'ho does such work himself or herself or through his or her ou'n employees. provided that such irnprovanents are nol intorded or offered for sale. lf. hon'ever. the tnrilding or funprovenrenl is sold s,ithin one )ear the purpose ofof cornplaion. the C)r,vner Builder will have the hrden of proving tha he or she did not h,rild or improve the sale). l. as os,ncr of the property. arn exclusi\,ely contracling contractors to construct the project Business theretrn.and ttofâ‚¬ssion ('ode: 'l'he (-'ontraclor's License l-au' does an o\!'ner of property $'ho builds and s'ho conlracts for such projects rvith a pursuant t() the conlractor's I aln exernl-rt .c. rbr t)ti( L.\R.\ Ito\ I hereby alTirm undcr penalty of perjury one of the follorving declarations: __l have and rvill maintain a Cerlilicate of Consent lo Self-lnsure for rvorkers' cornpensation. as provided for by Section 3700 of the Labor Code. for the pâ‚¬rfonnance of the work for rvhich the perrnit is issued. - _l have and rvill rnaintain rvorkers' cornlrcnsation insurance. as required by Section -1700 of the Labor Code. for the performance of the rvork for which this permit is issue<J. My rvorkcrs' compensation insurance carrier and policy number are: I'olicy -l certi$, that in lhe performance of thc s'ork for which this issued. I shall nclt and agree that ifl ernploy any person in , should become subject any manner t so as lo become subject to the workers' compensation larvs to the \r,orkers' cornpcnsation WARNING: I:ailure t<r provisions of Section 3700 of the l-ahrr I shall. forrhrvith cornply rvith those provisions. secure rvorkers' compensation coverage thousand dollars ($100.000). in and shall subject an to criminal civil fines up to to compensation.a Section -3076 Latxrr interest and attorney's fecs. I hercby alTirm under penalty of pcrjury that I arn licensetl of the Business and Professions Code. and my license is DECLARAI'ION under provision of Chaptcr 9 (commencing u'ith Section 7000) of Division 3 in full force and effect. l.icense _License Number: Dete:_('ortl ractrlr: CONSTRUC'IION LENDTNG ACENCY I hcrcby affinn undo pcnahy of pqjury that th6e is a construction lending agocy for the Jufomance of the work for which lhis pomil is issued (Se. 3097. Civ. C.). Lender's Narne: Lctttlct''s r\rltlt css. APPLTCAN DECLARA ION I herelry affirnr untler penalty of perjury one of the follorving declarations: Demolition Pennits-Asbestos Notilication Federal Regulations ('titlc 40. Parl6) --Required Lelter of Notification -- I certify lhat lhe federal regulations asbestos rernol'al are not I certify that I have read this application rvith all City and County ordinances and State [-as's relating to to enter above mentioned property for I A;lplicnrrt or Agcrtt Iternritee nanle state that the above infonnation is and / Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/Ve nUl n su latio n Roof Sheathins Shear Wall Framinq lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat Masonrv Pool Fence-[-Bar ]{andicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif. lt L' FINAL tloltlwJL,,t !\Ylnb*P/-kd) Certificate of Occupancy I Notes, Remarks, Etc. +On'ner: [ixpircs: