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BU!LDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION I hseby amrm undq pmalty of psjury that I m exempt from thc ConlmctoE' l,icffi llw for thc following tten (54.7031.5 Businos and Profesion Codc): Any City or County which requirc a pcmit to conslruct, alto. improvq demolish or repair my structue, prior to its issuucc, also require the applicilt for such pcnnit to file I signql statmot that hc or she is licosed purcuut to the provisiom of the Contractor's Liceroql krv (Chapts I, Commencing lvith Setion 7000 of Division 3 of thc Businas md Prcf6sionsCode)orthatheorshciscxemptthqcfromildlhcb6sisforthcallegcdermption. AnyviolalionofSccrionT03l.5byany applicant for a pmit subjcts the applicilt to a civil pmlty of not morc tha five hundred dollus ($500). __1. as owner of the propeny. or my etnployees with wages as their sole compensation. rvilldo the work and the structure is ntlt intended or offered for sale (Sec.7044. Business and ttofessions Code: 'l'he Contractor's License [,arv does not apply to an orvner of the propoly s,ho builds or improves theron. and rvho does such wort hinlself or herself or through his or her orvn employees. provided that such irnprovoncnts are not intended or offâ‚¬f,ed ftrr sale. lf. horvever. the building or funprovemc'nl is sold within one year of cornplaion. the (hvner Builder rvill have the burden of proving that he or she did not build or impnove the propoty for the purposc of sale). _1. as owner of the propefly. am exclusively contracting rvith licensed contractors to conslruct the project (Sec. 7044. Rusiness and Ftobsion Code: The Contractor's License [,arv does not apply lo an owner of property who builds or improvâ‚¬s thereon. and rvho contracts for such projects rvith a Contracto(s) licensed pursuant to the Contractor's License [aw). -l anr excmpt under Sc.ction-- B. & P.('. for this reason. l)nte: 0n ner: \\,0 RKF,ITS' ('0N I PI|NS;\TIO N DI,l('1,,\lt^'l'loN I heretrv afilrrn urrder pcrraltv oIpcrjurl,onc oIthc follorvinu dccl:rrations: __l have rrd will mintain 8 Ccnificate of Conmt to Selflnsurc for rvorkm' compmsation, r providcd for by SEtion -1700 of the l-abor Code for thc pqfomucc of lhe wort for which the permil b issued. ,A hayc m<! will maintain u,orkm' conrperuation imumnce. 6 requircd by Sation 3700 of the Labor Codc. for the pcrfonnecc of 'fhc uork for which this pemit is issucd. My workm' compersalion iroumcc cuicr od policy numbq rc: cuis:t@,^.,;":;;:@_?/___ _ __ .'xpire: *zllu<l- _l cqtily that in thc pqformancc of the work for which this Fsmit is issued. I shall not crnploy any [Emn in ily mflns so as to becomc subject to the \t'orkâ‚¬rs' compensation la\\'s of Calil'ornia. and agree lhat il'l should bec'ome suhject to the \r,orket's' cornpcnsation provisions of Section .1700 of the l.atnr (irde. I fortlnvith glunply u'ith thosc provisions. and shall subiect an crnplo)'er to criminal pcrralties andWARNIN(i: Failurc to secrrc \\'orkers' conll)ensation coveragc is ful. cir,il fincs up to one hundred lhousand dollars ($100.000). Section .i076 of the Labor Code. intcrest and attorney's fee{i. cost o[iorr, tlarrragcs as pt'ovirlcrl ftrr thc ,^r"r- /40/? I hereb-v alfirrrr under penalty of periury that I anr liccnserJ of Chapto'9 (corntttencing rvith Scction 7000) ol'l)ivision 3 of the llusincss and Professions ('ode, and rny liccnsc is in full lirrce ard eflect. / r-icense ct^"r, ' blOA-?70__License a r)arc: ' 2/la /t q ('onlraclor: I hereby affrm under penalty of perjury that there is a constnrction issued (Scc. 3097. Civ. C.). l,ender's Name: agency for the perfonnance of the u'ork for nhich this p,ermit ls l.endcr's Adtt'ess: - A PPLICAN'I' DEC I,ARA'I'ION I haeby affirm under penalty of perjury one of the follorving declarations: Dernolition Perrnits-Asbestos Notilication Federal Regulations (Tille 40. Pan6) -Required l,etter of Notification __l certify'that the federal rcgulations rcgar<ling astrc'stos rernoval arc not applicablc to lhis project the ahrve inf<rnnation is corrcct. I agree to cornply w'ith all City and County and hcrctry authorize rept'escntalives of this City and County to enter up)n the \pplicnrrt or,\gcnt Signature: * I l'errnitec name (print):* - r)nre: . U/23/2 Set Backs Forms/Steel/Holdowns Lq Dkff)a .En Erection Pads ,I UFER Ground SLAB Floor S u bfloor/VenUl n su latio n Roof Sheathinq Shear Wall Framing lnsulation/Enerqy Drywall Ext./lnt. Lath Brown Coat JVlasonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Fina! Report Flood Zone Certif I FINAL il 2<fi I)k{v),tu^VKe/ Certificate of Occupancy ,I lr Notes, Remarks, Etc,\ nlz?llq- vqn<kot>I L I I I -+I have reaclthis application arrtl State [.aw's rclating to building rncntionctl prope(y lor inspcction l,l C