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BU!LD!NG- INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER I'EI,CARATION I hseby amrm unds pcnalty of psjury that I m exqnfl fiotn the Coilracto6' Liccns law for the following llen (56.7031.5 Buinqs and Profesion Code): Any City or County which rcquira a pornit to construcl. ahs. improvq &rnolish or repair uy structue. prior to its isuancc, also requirG thc applicol for such pmnh to file a siSned stalmmt lhat hâ‚¬ or shc is licascd pmuol lo the prcvisioro of the Contrrctor's Licensed t-aw (Chapts 9, Commcncing with Sstion 7000 of Division 3 of the Businos od PrcfsionsCode)orthathcorsheisexemptthqefromudthebasisfortheallegcdermption. Anyviolationofs(tion703l.5byany applicatrt for a psmit subjcts the applicant lo s civil poalty ofnot morclhm five hundrcd dollas ($500). _1. as owner of the property. or my employees with rvages as their sole compensation. rvilldo the rvork and the struclure is not intended or offered for sale (Sec.7044. Business and Professions Code: The Contraclor's License Law does not apply to an orvner of the prop'rry who builds or funproves therqrn. and rvho does such $'ork himself or herself or through his or her orvn etnployees. providd that such irnprovonents are not intended orofferd for s:rle. l[, hos'ever. the building or improvement is sold within one ]Ear of cornplaion. the Orvner Builder rvill have the bnrrden of proving tha he or she did not build or improve the propoly for the purpt)se of sale). _1. as o\\'ner of the properly. am exclusively contracting rvith licensed conlractots to construct the project (Scc. 7044. Business and Profi:ssion Code: 'fhe Contractor's License Law does not apply to an orvner of property rvho builds or improves thereon. and rvho contracts for such projects with a Contractor(s) licensed pursuant to the ('ontractor's License Law). --l arn exempt under Section-. B. & P.C. for this reason. Dnte: Owner:_ WORKERS' COMPENSATION DECLARA'I'ION I hereby affrrm under penalty of perjury one oIthe follorving declarations: __l have and rvill maintain a Certificate of Consent to Self-lnsure for rvorkers' compensation, as provided for by Section 3700 of the Labor Code. for the perlormance of the work for which the pennit is issued. I have and will maintain workers' conrpensation insurance. as required by Section 3700 of the Labor Code. for the perforrnance of *-: -:*'*'''ol'"' , Expires: 41+^-_r-Policv Number: _l certify that in the performance of the work for rvhich this permit is issued. I shall not employ any person in any mann(t so as to become subject to the rvorkers'compensation laws of California. and agree that if I should bccome subject to the workers' compensation provisions of Section 3700 of the Labor Code. I shall. forthwith comply with those provisions. i WARNIN(i: Failure to secure workers' cornpensation covemge is unlarvful. and shall subject an onployer to crirninal penalties and civil fines up to one hundred thousand dollars ($100.000). in addition of compensation. darnages as provided for the Section 3076 of the Code, interest and attorney's I hereby affirm under penalty of perjury that I arn licensed under provision of Chapter 9 (commencing rvith Section 7000) of Division 3 of the lltrsiness ancl Profcssions ('odc. and rny license is in full force ancl cfl'ect. ) License ('lass: l)alc:-h I heeby aflirrn undo pmalty ofpojury that thse is a constnrction letrding agency for thc pofonnancc ofthe work for rvhich this Snmit is issued (Sec. 3097. Civ. C.). Lender's Name: l .cttrlcr's Arlth'ess: APPLICAN'T DECLARA'IION I ho'eby alfinn under penalty of perjury one of thc follorving declarations: Dernolit ion Pennits-Asbestos Noti fi cat ion Federal Regulat ions ('l'itle 40. I'ar16 ) -Required l,etter of Notification -l cerlify that the federal regulations regaldirrg asbestos rcrnoval arc not applicable to this project. I ceflify lhat I have read this application and state that with all City and County ordinances and State [.arvs relating to artd 'L'ruj;"alxrve rncrrtioncd propeny lbr Applicant or Agent l'ermilee nBme (print): -o.,"' I Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloor/VenUl n su latio n Ropf Sheathing K-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 I FINAL I b 'l.a P.A ?061 -vyl Certificate of Occupancy Notes, Remarks, Etc rr+ ,