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BUILDING. !NSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OIVNER BUII.DER DELCARATION I hqctry allirrn unds penalty of pfjury that I m exempt from the ContractoE' l-icosc l-arv for rhc following rcNn (56.703 r.5 Businss md Profsion Code): Any City or County rvhich rcquire a pcrrnit to @Ntrucl. alto. improvc. dmolish or rlpair any structue. prior lo its ismce, also rcquirB the applicant for such pemit to file a signed slalcmmt that he or shc is licosed puEuilt to thc previsions of the Contractor's Licmsed taw (Chapts 9. Commcncin8 with Sstion 7000 of Division 3 of tltc Busines artl I'rofessions Code) or that hc or she is exenpt thqefrom ild the basis for the alleged excrnption. Any violation ofsstion 7031.5 by {y applicanl for a pennit subjcts the spplicant to a civil pcnahy ofnot morc thm live hundrcd dollm ($500). _ l. as owner of the propcrly. or my employees with wages as their sole cornpensation. willdo the rvork and the structure is not intende<l or offered for sale (Sec.7044. Business and Professions Code: The Contraclor's License Larv does not apply to an orvner of the propctty rvho builds or impro\,â‚¬s thcrmn. and u,ho does such \r'ork himself or herself or through his or her orvn employeâ‚¬s. provided that such irnprovonents are not intended or offered for sale. I[. horvever. the building or improvemenl is sold rvithin one year of cornploion. the Orvner Builder rvill have the burden of proving that he or she did not build or improve the propoly for the purpose of sale). _1. as owner of the propefly. am exclusively contracting with licensed contractors lo construct the project (Sec. 7044. Business and Profrssion Code: The Contraclor's l-icense Larv does not apply to an o$'ner of property rvho builds or improves thereon. and rvho contracts for such projects rvith a Contracto(s) licensed pursuant to the Contractor's License [an'). _l am exempt under Section_. B. & P.C. for this reason. Date: 0wner:_ WORKERS' COMPENSATION DECLARATION I hereby affrrm under penalty of perjury one of the follou'ing declarations: .--l have and rvill maintain a Certificate of Consent to Self-lnsure for rvorkers' compensation. as provided for by Section 3700 of the Labor ('ode. for the pei'formance of thc u'ork for rvhich the perrnit is issued. --l havc and will maintain workers' cornpensation insurance. as required by Section -i700 of the Labor Code. for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: c o. . ZC{rl Oh Policy t w '1 +(77tQi ,-rrr";' t+/l kO _.1 cerrify that in the performance of the u'ork flor rvhich this perrnit is issued. I shall not employ any person in any manner so as to become subject to the \r,orkers' cornpensation larvs of California. and agree that if I should become subject to the rvorkers' cornpensation provisions of Section 3700 of the l.atxrr Code. I shall. forrhrvith cornply rvith those provisions. WARNINC: Failure to secure rvorksrs' compensation coverage is unlarvful. and shall subject an ernployer to crirninal penalties and civil fines up to one hundred thousand dollars ($100.000). in addition to the cost of cornpensation. damages as provided for the Section 3076 Code. interest and attorney's fees. t x .l 9 (comnrencing with Section 7000) of Division 3I hercby affinn under penalty of perjury that I am licensed of the License Business and Professions Llo and my license is in firll force and eflect. crlL 8(-)55a l,icense Nurnber: ^t.-) l)ate: 'ttfs/ n Contracto,, CONSTRUC'IION LENDING AGENCY I hrcby aflirm undcr penalty of pcrjury that thqe is a construction lcnding agacy for thc pofomce of thc work for which this pennh b issued (Ss. 3097, Civ. C.). Lender's Address: APPLICAN'T DECLARATION I herelry afiinn under penalty of perjury one of the follorving declarations: DernoIition Perrnits-Asbestos Notification Federal Regulations (Title 40. Part6) -Rcquired Letter of Notification _l cqtify that the fedaal rcgulatiom rcgoding 6b6tos rqnoval ile not applicablc to this prcjat. Yt ccriS rhar I havc md this application ud stalc that thc above infomarion b corcc{. I agrcto @mply with all Cityild County oldiiancc md Statc taws rclating to building costructioG ud h6cby authorizc rcpr6c[tativ6 of this City ud County to 6ts upon thc ff"::;;J:il,L permireeneme(prirr), F foD?fh C(eftraj-- ,,,", - l(f s/ n Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/Ve nUl n s u latio n Roof Sheathing Shear Wall Framing Insu !ation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report -Flood /qne pertif,I ltdal KftrALt(\Wr '11 WO lW,tlU,#l ffi \/1 FINAL I '01 wfi)$\f/ruoc @ Certificate of Occupancy It Notes, Remarks, Etc.