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BUILDING. INSPECTOR RECORD SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcreby allirm undcr Fnalty of Frjury that I am crcmpt trum thc Conlraclon' Liccnsc Irw for lhc folktwing rcaen (Se.70.11.::. Busincss anl Prcfcssion Cqtc): Any Cily or County which rcquircs a lrrnil to conslrucl. altcr. improvc. dcmolish or rcpair any structurc, Fior to ils issuancc. also rcquircs thc applicant li)r such lrcmil lo filc a si8ncd slatcmnt that hc or she is liccn*d putr lf b thc pruvisions of thc Contrack['s Liccnscd Law (Chaplcr 9. Commcncing wilh Scclion 70([ of Division .] of thc Busincss anrl r PmfcssionsCodc)orthathcorshciscxcmptthcrcfromandthehasisforthcallcgcdcrcmplion. Anyvi(rlalionofscclionT0ll.5byany applicant for a Frmil suhjccts thc {pplicant to a civil pcnalty of noI morc than fivc hundrcd dollars (S5U)). _l.as owneroftheproperty.ormycmployccswithwagesasthcirsolcconrlrcnsalion,willdolhcworkandthestrlx.*tureisnot intcrdcd or oll'cred tbr sale (Scc.7M4, Busincss and Prolbssklns Ctxlc: Thc Contractor's Liccnsc Law does not apply to an owncr of the pnrJrcrty who huikls or improvcs thcrc-on, and who drrcs such work himself or hersclf rtr through his or hcr own employecs, providcd that such impnrvcmcnls arc nol intendctl or ollbrcd lbr salc. Il, howcvcr. thc huilding or impr)vcrncnt is sold within ()nc yctu of cornplction, tlrc C)wncr Buiklcr will havc thc burdcn of proving that hc or shc did not huild rlr improvc the pnrpcrty tor thc purglse of salc). _1. as owner of the prrlpcrty. am cxclusivcly conlracting with licenscd conlraclors to construct lhc pnljcct (Sec. 7M4, Busincss and Pnlfbssion Codc: 'l'hc Conlractrlr's l.iccnsc Law docs not apply to an owncr o[ propcrty who builds tlr improves thcreon, and who contracts tbr such projccts with a Contractrlr(s) liccnscd pursuant to thc Contractor's Liccnsc Law). -IamcxemptunderSection-.B.&P.C.tbrlhisrcason. WORKERS' CONI PENSATION DECLARATION I hcrehy all'irm undcr pnalty of Jrcrjury onc of thc tirllowing rleclarations: _l havc and will mrintain a Ccrtilicatc o[ Conscnt to Sclt-lnsure tor workcrs' compcnsation, as pnlvidcd tirr by Scction 37fi) of thc Latxlr Codc, tirr the pcrlirrmancc o[ thc wrlrk ltrr which the pcrrnit is issucrl. rcquircd hy Sccliorr J700 ol'thc Lahor Codc, ftlr the pcltilrmancc ol'_l lravc and tltc work lilr will nraintain wrlrkr-rs' cotnpcttsalirlt is issuctl. My wrlrkcrs'insurancc carricr and gllicy number arc: Policy ?o<a _l ccrtil'y that in thc perlilrmancc ol'tlrc wrlrk klr which this pcrmit is issucd. I shall nol cmploy any lrcrson in any manncr so as to bccome subjcct to the workers' cornlrcnsation laws of Calitbrnia. anrJ agrcc lhal if l should hcconrc subiect to thc workcrs' comlrcnsation pnlvisions of Scction 3700 of thc Latxlr CuJc. I shall. lirrthwith comply with tlxrsc provisions. WARNING: Failure t() sccurc workcrs' conrJrcnsation covcragc is unlawful, and shall suhjcct an cmpkryer to criminal Jrcnaltics and civil lines up to one hundrc'rl lltousand of comlrcnsalion, damagcs as providcd lirr lhc Scction 1076 of the Labor Gxle, ??'. arttl lhlc:(t f q(- LICENSED CONTRACTOR DECLARATTON I hcrcby al'firrn undcr pcntlty ol pcrjury that I anr liccnscd undcr provision of Chaptcr 9 (contnrcncing with Scction 7000) of Division 3 ol' thc Business and Pnrlbssions Codc, antl my liccnse is in hrll lilrcc antl ct't'cct. l.iccnsc C Nurnbcr:SL(LA (( W I hercby affrm under Fnalty of Frjury that thcrc Ls a snstructhn bnding egerey for thc trcrlbmne of thc mrk fur which this ]Emil is issucd (Ss. -!097, Civ. C.). [Inder's Namc: [.cnder's Addrcss: APPLICANT DECLARATION I lrcrcby altirm undcr pcnalty ol'lrcrjury onc of lhc titllowing dcclaratiotts: Dcmolition Pcrmits-Asbcslos Notilicatirln Fcdcral Rcgulltions (Titlc 40, P:rrt6) -Requircd lrttcr ot' Notilicalirtn -l crnily thal the fcderal rcSulations rc8.mlin8 ashcslos rcmval rc ml applicahlc to this pfttitt. _l ccrtily that I havc rcad thls applicati()n url slalc lhal thc alxrvc inli)rmathn is corccl, I a8rc lo comPly vilh all City and Counly onlinanccs and State lass rclaling to buildinS constructio[ dxl hcrcby authorizc rcp]csctrlativcs ofthis City atrd County to cntcr ulbn thc atxlvc mcntioned proprty lilr Applicant or Agent Perlnitee nanle n t., f t' la' C7 Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenVI nsu lation I I lt ^,d Roof Sheathinq ilr'[n ll/tZ*til apu Shear Wall lj Framinq Insulation lEnerqy Drywall Ext./lnt. Lath Brown Coat Masonrv Pool Fence T-Bar Handicap Req. Deputy Final Report Enqineer Final Report Flood Zone Certif ^ /^ l. ^,l /l -) 1a) FINAL l,L/ 5/1'r .PLY Certificate of Occupancy Notes, Remarks, Etc.