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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG-COMMENTS OWNER BUILDER DELCARAI'ION I hocby affim undo penalty of pajury that I m cxempt from lhc Contraclon' License Law for thc following rffin (58.7031, llusinBs ed Prof*ion Code): Any City or County which requirc a pwnit to corolruct. ahe, improve. donolish or repair any struc1[e, prior to its issuuce. also rcquirc the applicmt for such pcnnit to lilc a signed statmal that hc or shc b licmsed pmuilt to the Eovisions of thc Contractor's Licmscd law (Chaptd 9. Commencing with Setion 70O0 of Division 3 of the Busines md I Prefe$ions Code) or that he or shc is exonpt thocfiom od the b6is for the allegcd cxmpion. Any violation of S6lion 70-l1.5 by any applicantforapennitsubjetsthe applicanttoacivilpcnaltyofnotmorcthulivehun&cddollus($500). t --1. as o\\,ner of the property. or my employees with rvages as their sole compensation. rvilldo the rvork and the structure is not intendoJ or oflered for sale (Sec.7044. Business and Professions Code: I'he Contraclor's License Larv does not apply to an orvner of the proper-ty rvho builds or improves theron. and rvho does such u'ork hirnself or herself or through his or her orvn employees. provided that such irnprovanerts are not intended or offered for sale. If. hos'el'er. the building or improvemcnl is sold rvithin one year of complaion. the Orvner Builder rvill have the hrden of proving tha he or she did not build or impnove the propory for the purpose of sale). --1. as o\r'ner of the property. am exclusively contracting rvith licensed contractors to construct the project (Sec. 7G14. Btsiness and Profession Code: The Contractor's License Law does not apply to an o\r'ner of property rvho builds or improves thereon. and rvho contracts for such projects with a Contracto(s) licensed pursuant to the Contractor's License [-arv). --l arn exempt under Section-, B. & P.C. for this reason. Date: Owner:_ WORKERS' COIIT PENSATION DECLARATION I hereby alTirm under penalty of perjury one of the following declarations: -_l have and will rnaintain a Certifrcate of Consent to Self-lnsure for rvorkers' cornpensation. as provided for by Section 3700 of the Labor Code. for the performance of the work for rvhich the pennit is issued. _l have and will maintain workers' compensation insurance. as required by Set'tion 3700 of the l,abor Code. for the performance of the work for which this permit is issued. My rvorkers' compensation insurance carrier and policy nuntber are: . *tmL(tdn ?,){ (c l^ tkrlicy Nr,,,b.r, J lYv{,-- fM - .a l:x prrcs:ttf t/zo _-__ I cerlify that in the perforrnance of the rvork for which this permit is issucd. I shall not ernploy any person in any tnanner so as to become subject to the rvorkers' cornpensation laws of California. and agree that if I should become subject to the rvorkers' compensation provisions of Section 3700 of the l-abor Code. I shall. forthrvith comply with those provisions. WARNING: Failure to secure rvorkers' compensation coverag,e is unlau,ful. and shall subject an onployer to criminal penalties and civil fines up to one hundred thousand dollars ($100.000). in acldition to the cost of contpensation. dzunages as provided for the Section 3076 of the Labor Code. interest and attorney's fees. ,D( DECLAITA'I'ION I hereby alTirnr under penalty of perjury that I am licensed under provision of Chapter 9 (commencing rvith Section 7000) of I)ivision 3 of the Business and Professions Code. and nry license is in full force and effect. LLicenset License Number:a t' a (.onrrrcrn., il )q,,ict w1q) ('ONS'l lr[ ('l ION l.l:Nl)lN(; ,\(;l':N('\ I hreby affirm undo pmalty of perjury that thre is a construction hnding agocy for thc pofomace of lhe rvork for shich this glnit is issued (Sec. 3097. Civ. C.). lrnder's Name: Lerrder's Address: APPLICANT DEC LARA'I'ION I hffiby affrnn under penalty of pe{ury one of the follorving declarations: I)ernoIition Permits-Asbestos Notification Federal Regulations ('l'itle 40. Pat6) - Required Letter of Notification I cotify (hat lhc federal regulalions rcgoding mltsftrs rcntrval arc n()l flil)licahlc lo lhis lnr)jcct. h/ I corify that I have ru<J this applicalion ard statc thal lhe alxrvc inftrrnratior is conrl. I alrc lo coilrply wilh 0ll ('ity and (iNoty :il1T:ffilfiTfJff;X1lli*,:,"'iif.::lsn'criut' ild hcrcr)v 'utrx)rirc rcptscnratilcs orthis ('i(v atrd (bu*]: 1'"j':' u' ;,,,,;";;;;.;;;,;*-,-,-,r )2 ,),,e: ' lllZl/"1 I'er,ir(rtrane(priru,*- DqqLcl vqrgqs Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloor/VenUl nsu lation Roof Sheathinq Shear Wall Framinq lnsulation/Enerqy Drywall Ext./lnt. Lath Brown Coat J\4asonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Ffood Zone Certif FsubV fAlrN,T 12.-fu-l' FINAL lz-zo-)L Certificate of Occupancy (\/ Notes, Remarks, Etc. -t ,*", - ll fd/tq 0 I r\WLY rW),ilt