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BUILD!NG. INSPECTOR RECORD SITE.WORK DATE !D/SIG.COMMENTS OWNER BUILDER DEITARATION I hcreby allim unds pdalty of pqjury that I m exempt liom the Contracto6' LiceNc Law for the following r@n (5(.7011.5 Busincs and Profesion Codc): Any City or County which require a po'rnit to construct, altq. improvq demolish or rcpair lny struc(uc. prior to its issuace. also rcquir6 thc spplicsnt for such pemit to filc a signcd statanf,t that hc or she is licmscd pmuilt to thc provisioos of thâ‚¬ Contractor's Liccnsed Lau' (Chsptq 9. Commencing with Strtion 7000 of Division 3 of the Busines ffd Profe$ions Code) or that he or shc is exempl thqefrom ed the basis for thc alleged exmption. Any violation of Sdion 70-11.5 by any applicantforapenuitsubjatsthc applicanttoacivilpenaltyofnotmorethmfivehundreddollus($500). _1. as owner of the Fnoperty. or my etnployees with wages as their sole cornpensation. rvilldo the rvork and the struclure is not intended or oflered ftrr sale (Sec.7044. Business and Professions Code: l'he Contractor's l.icense Larv does not apply to an ou'ner of the pnrpcrty u,ho hrilds or improves thercon. and s'ho does such rvork hirnself or herself or through his or her orvn employees. provided that such improvonents ile not intended or offered for sale. If. horvever. the building or hnprovexlent is sold rvithin onc year of comploion. the Orvner Builder will have the burden of proving that he or she did not build or irnprove the propoty for the purpose of sale). - I. as o\!'ner of the property. am exclusively contracting rvith licensed contractors to construct the project (Sec. 7044. Brciness and Pnrfession Code: 'l'he Contraclor's License Larv does not apply to an o$'ner of property who builds or improves thereon. and u'ho contracts for such projeas with a Contracto(s) licensed pursuant to the Contractor's Licerse [arv). -IamexemptunderSection-.B.&P.C'forthisreason.l)ate: On ner: _ \\'0 ttK E RS' (:01\t t,t:N sA't't()N I)E('LAIt t't't(tN I herclly affirrn under pcltalty of perjury ortc of lhe ftrllou'irrg clcclarations: _l havc ild will maintain a Cstificatc of ColMt to SelfJEure for rvorkc' compensatioo. a providcd for by Sstion 3700 of thc Labor Codc. for thc pcrfomcc of thc Eork for which thc pmit b isucd. -l havc and will maintain rvorkm' compmation ireurance. r requircd by Sction 3700 of thc Labor Codc, for the pqfomflcc of the work for which this pcmit is issued. My work6' compmsation insuruce cmiq ed policy numbs oE: /.-,.,- 5|qle Tvrs. 'F,.rn\' il;;;- r-lq -, -l cqlify thal in thc pcrfomncâ‚¬ of lhc work for which this pqmit is issued. I shall not mploy any pmon in any muner s re to bcome subjct to thc wortm' comperoation laus of Califomia. and agrc that if I should bccomc subjat to the rvor*m' ompwtion prcvisioro of Setion 3700 of thc lrbor Codq I shall. fonhwilh comply with thos prcvisios. WARNING: Failurc to suc rvorkm' compmdion col,m8c is unlawful. md shall subjct u opbya to qiminal pqultis ad civil fines up to one hundrcd thousmd dollm ($100.000). in addition to thc cosl of compcution. dmagc r provided for the 1 Section iT'j'iH:i"q*and attorney's fees. o1A/ DECLARA'TION I hercby affirm under penalty of perjury that I arn licensed under provision of Chapter 9 (cornmencing with Section 7000) of Division 3 of the Business and Professions Code. and my license is in full force md eflect. 1'"-"it-ffi Nunrbc'r: q5 ,-{ (lonlrRctor: f,Ro 59e-c;q \ SIS CONS'I'RI.J("TIoN I,ENDING AGEN('\' I heeby affirm undr pcrslty of psjury that th@ is a congructioo hnding agmcy for thc pcfomilcc of thc work for ntich this Fmit b issucd (Se. 3097. Civ. C.). Lends's Name: Lender's Ad<lress: _ APPLICAN'T DEC LARA'TION I hortry affrm under penalty of perjury one of the following declarations: Dernolition Perrnits-Asbestos Notification Federal Regulations (Title 40. Part6) -Required lrtter of Notification _l corify that the federal regulations regarding asbestos rernoval are not applicable to this project. I corify that I have read this application and state that the above inforrnation is correct. I agree to comply rvith all City and ('ounty and County to â‚¬nter ugrcn the _1 \-28-.8',:;|,;;ffi,illj1::fftrl.ilffifuilding construction. and hereby authoriz.e representativcs of this citv soricnntorAsenrsipnarure: ffirlb b/^h/1/ Dare: ---v-- Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloor/VenUl ns u lation Roof Sheathins //-Zd - I q t8r*/o> Shear Wall Fram !nsulation/Energy Dryruall Ext./lnt. Lath Brown Coat [\Iasonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif FINAL //'r-'7-fq fr68./aa Certificate of Occupancy Notes, Remarks, Etc. \ \ / \