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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/S!G.COMMENTS OWNER BUILDER DELCARATION I hscby aflim undo ymalty of perjury that I m crempt from thc Contraclos' Licffe lrrv for thc following r@n (Ss.7031.5 Bsin6s md Profxion Codc): Any City or County which rcquiro a pcnnit to costruct, altc. improve. dcmolish or repair any structurc. prior to its isuancc. aho rcquirG the applicant for such pennit to filc a sigtrcd starmot that hc or shc b licfisd puEuilt to thc prcvisioG of the Contraclor's Liccnscd Law (Chaptq 9. Commcncing with Sction 7000 of Division 3 of the BNins ild Prcfc$ions Codc) or that hc or she is cxcmpt thqcfrom dd the basis for thc allcgcd exmplion. Any violation ofScrrion 703 I .5 by any applicantforapcnnitsubjetsthe applicanttoacivilpenaltyofnotmorclhufivchundreddollas($500). . __1. as owner of the properly. or rny ernployees with rvages as their solc compensation. will do the rvork and the struclure is not intended or offered for sale (Sec.7044. Business and Professions Code: l'he Contractor's License Law does not apply to an owner of the prnperty who builds or irnproves therqrn. and rvho does such u,ork hinrself or herself or through his or her own employees. provided that such irnprovanents are not interded oroffered for sale. lf. hou'e','â‚¬r. the building or imptovetnent is sold within one year of cornpletion. the Owner Buildcr u.ill have the burden of proving that he or she did not build or improve the propory for the purpose of sale), _1. as owner of the properly. am exclusively contracting rvith licensed contraclors to construct the project (Sec. 7044. Business and ProfEssion Code: The Contractor's License Law does not apply to an os'ner of property rvho builds or improves thereon. and who contracls for such projects rvith a Contracto(s) licensed pursuant to the Contraclor's License Lau'). _l am exempt under Section_ -, B. & P.C. for this reason. I )rl t':0wner'-- WORK ERS' COI\I PT]N SA'I'IO N DECl,ARA'tION I hereby afTinn under penalty of perjury one of the follorving declarations: ,-l have and rvill rnaintain a Certificate of Consent to Self-lnsure for rvorker':s' compensation. as provided for by Section .3700 of the Labor Code. for the pei'formance of the rvork for rvhich the pennit is issued. _l have and s'ill maintain rvorkers' cornpensation insurance. as required by Section -1700 of the l-abor Code. for the po'formance of the work for which this permit is issued. My s'orkers' compensation insurance ciurier and policy number are: _ I cerlify that in the pcrforlnance of the rvork for which this pennit is issued. I shall rrot ernploy any person in any manner so as to become subject to the rvorkers'compensation larvs of California. and agree that if I should become subjecl to the w,orkers' compensation provisions of Section 3700 of the l,abor Code. I shall. forthrvith comply rvith those provisions. WARNING: Failure to secure rvorkers' cornpensation coverage is unlarvful. and shall subject an onployer to crirninal penalties and civil fines up to one hundred thousand dollars (S100.000). in addition to the cost of compensation. darnages &s provided for the Section -3076 of the Labor interest and attorney's fees.q I hereby afllrrn under penalty of perjury that I arn licensed under provision of (-hapter 9 (commencing rvith Section 7000) of l)ivision -3 of the Business and Professions Code. and my license is in full force ard efTect. License Class:- l)ntc: CONSTRUCTTON LENDING AGENCY I hrcby affm undo pcnalty of pcrjury that th@ is a @nsruclion knding agocy for thc perfomce of thc work for vhich Ihis permil b issucd 1Se. 3097, Civ. C.). I.ender's Narne: Lender's Address: APPLICAN'I' DI:(:LARA'TION I ho'crby alfirrn under pcnalty of pcrjury one of the following declarations: I)erno lition Perrnits-Asbcrstos Not i fi cat ion Federal Regulat ions ('Iit le 40. Pan6 ) _Required Letter of Notification _l cerrify that the federal regulations regarding asbestos removal are nol applicable to this project. I c6tiry that I have red this application ild state that the above infonnation is const. I agrc lo comply with all City 8nd County odinancB ild Statc krvs rclating to building corotruoion. md hseby authorizc rc!tr66tariv6 of this City nd County lo ql6 uponlhâ‚¬ above mentioned property for inspection ,\11;llicalrt or Agcrtt l)ermilee narne (print):-+t/1/- Date:-!W4l)a? Set Backs Forms/Stee!/Holdowns Erection Pads UFER Ground .SLAB Floor Su bfloor/VenUl nsu Iation Roof Sheathing Shear Wall Framinq lnsu lation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif. FINAL /zd7- /?F. c /5^'c da; e 17 Certificate of Occupancy Notes, Remarks, Etc.