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BUILDING. INSPECTOR RECORD S!TE.WORK DATE ID/SIG.COMMENTS OWNER BUII.DER DELCARATION I hseby amrm undq penalty of pcrjury thst I fln crqnpt from the ContractoB' Licw law for the following rcen (56.7031.5 Busines md Profsion Code): Any City or County rvhich requirs a pomil to construcl. altq. imprcvq dmolish or rcpair a'ry structuc. pdor to its isuancc. also requirG thc applicant for such pcmit to filc a signcd statmqt that he or shc is licdEcd pu6uu, to the provisions of the Contractor's Liccnscd lrs (Chapls 9. Commcncing with S(tion 7000 of Division 3 of lhc Busins ild Prcf6siomCodc)orthathcorshcisâ‚¬xemptthqcfromudthcb6sisforthcallcgedcxmption. AnyviolationofsdionT03l.5byany applicant for a pamit subj*ts the applicant to a civil pmalty of not morc thil five hundrcd dollrs ($500). -_ l. as owner of the propefly. or my employees with rvages as their sole compensation. will do the work and the struclure is not intended or offered for sale (Sec.7M4. Business and Professions Code: The Contraclor's [.icense Law does not apply to an owner of the properly who hrilds or improves theron. and who does such wort himself or herself or through his or her orvn employees. provided that such inrprovonents ile not intcnded or ofFâ‚¬red for sale. Il. horve'/er. the btrilding or itnprovement is sold rvithin one ycu of complaion. the Orvner tsuilder will have the burden of proving that he or she did not build or irnprove the propory for the purposâ‚¬ of sale). __1. as o\r'ner of the property. am exclusively contracting with licensed contractors to construct the project (Sec. 7M4. Business and I'rofession Code: The Contractor's License Larv does not apply to an owner of property w'ho builds or improves thereon. and rvho contracts for such projects rvith a Contracto(s) licensed pursuant to the Contraclor's License Larv). -l arn exempt under Section---, B. & P.C. for this reason. I)ate:Orr':ter: WORK IiRS' COI\I PENSA'I'ION DECLARATION I hereby aflirnr under penalty of perjury one of lhe follorving declarations: _l have and will rnaintain a Certificate of Consent to Self-lnsure for workers' compensation. as provided for by Section 3700 of the Labor Code. for the performance of the work for rvhich the perrnit is issued. _l have and rvill maintain rvorkers' compensation insurance. as required by Section 3700 of the Labor Code. for the pcrfonnance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number ,*rr"r, kJ "*c,,J H-{,. < d C a5' t.r.l(V are: policyNurnuer CAU. CCi.3C, i Y ? Expircs:LO __ I cerrify that in the perforrnance of the work for rvhich this permit is issued. I shall not ernploy any person in any manner .a so as to become subject rvorkers' compensat ion to the rvorkâ‚¬f,s' compensation larvs of California. and agree that if I should becorne subject to the provisions of Section -1700 of the Labor Code. I shall. forrhrvith comply provisions. WARNING: Failure to secure rvorkers' compensation coverage is unlas,ful. and shall subject to crinrinal pnaltics and civil fines up to one hundred thousand dollars ($100.000). in addition to cost of damages as provided for the Section -1076 Latxlr Code. interest and attorney's fees. /r q v- I hereby affirrn under penalty of perjury that I arn licensecl under provision of Chapto'9 (comntencing rvith Section 7000) of Division -3 of the Business and Professions Code. and nry license is in full force and effect. License ct "", C'- 3 1 Nurnber: o,t", /r /(. // f I hrcby affirrn undu penalty of perjury that thqe is a comtruc{ion lending agmcy for the Ju'fonnmcc of the work for rvhich this pqmit b issued (Sec. 3097. Civ. C.). Lender's Narrre: I-enclcr's Adclress: APPLICANT DECLARATION I hereb,y affrnn under penalty of perjury one of the follorving declarations: Dernolition Permits-Asbestos Notification Federal Regulations (f itle 40. Parr6) -Required Letter of Notification _l certify that the federal regulations regarding asbcstos rernoval are not applicable to this project. _ -- l cerrify that I have reacl this application and statc that thc alxtve is con'cct. I agrcrc to comply rvith all City ancl ('ounty ordinances and State Larvs relaling to building attrl represefltatives of this City and Countyld/enter upon the /q above tnentioned propet'ty for inspection Applicnnl or rtgcnl (-L--\ Permitee neme QAnO: FFrZ-A t *t e k4 u-F Z Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloor/Ve nUI nsu latio n , Roof Sheathing il-?s ///fu.t ,ry Shear Wall / Framing lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif FINAL /l-?C.- I 9 E*t/ot Certificate of Occupancy Notes, Remarks, Etc. 3 Contractor'}(r