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BUILDING. INSPECTOR RECORD SITE.WORK DATE !D/SIG.COMMENTS OWNER BUILDER T'ELCARATTON I hoeby aflim uds pcnalty of pedury that I an exmpt fiom the Contraclon' t-icw Larv for the follorving rcen (3(.7031.5 Busines and Prof6sior Code): Any (:ity or Counly which requira a Jmit to Nnstrucl. altq. improvc. dqnolish or repair af structue. prior to its isuece. also rcquirs thc applicant for such pctmit to file a signed stalonal that he or shc is licf,rd pmuirl to the provisions of the Contractor's Licosd law (Chaptq 9. Cornmencing rvith Sstion 7000 of Division 3 ofthc Busines and PrcfcsionsCodc)orthathe orshe iscxcmptthqefromandthe basisfortheallâ‚¬gedermpion. AnyviolationofScclhnT0.rl.5byany applicantforapennitsubjststhe applicanttoacivilpenaltyofnotmorelhmfivehundreddollm($500). __1. as owner of the propetly. or my employees with rvages as their sole compensation. rvilldo the work and the structure is not intended or offered for sale (Sec.7044. Ilusiness and [tofessions Code: The Contractor's l.icense Larv does not apply to an o\\'ner of the propoly who builds or improves thermn. and rvho does such work hirnself or hcrself or through his or her own employees. provided that such improvonents are not intendd or ofFered for sale. lf. hos'ever. the building or itnprovement is sold rvilhin one yea.r of cornpletion. the Orvner Builder will have the burden of proving that he or she did not build or irnprove the propo'ty for the pupose of sale). _ l. as owner of the property. am exclusively contracting rvith licensed contractors to conslruct the project (Sec. 7M4. Business and Profiession Code: l'he Contractor's License Law does not apply lo an owner of property rvho builds or improves thereon. and who contracts for such projects rvith a Contracto(s) licensed pursuant to the Contractor's License Law). --l am exetnpt under Section-. B. & P.C. for this reason. . l)alc:Orr lrcr': WORKERS' COIIT PENSATION DECLARATION I hereby affrnn under penalty of perjury one of the follorving declarations: _l have and will maintain a Cerrificate of Consent to Self-lnsure for rvorkcrs' compensation. as provided for by Se<tion -3700 of the Labor CocJe. for the perfonnance of the work for rvhich the pennit is issued. -l have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code. for the performance of the rvork for rvhich this pennit is issued. My rvorkers' compensation insurance carrier and policy number are: Carrier: Policy Nurnber:_ -Expircs: - __l certify that in the perforrnance of the rvork for w'hich this perrnit is I shall not 8ny manner , to thcso as to become subject to the rvorkers' compensation larvs agree that ifl rvorkers' cornpensation provisions of Section .1700 of the l.abor provisions. WARNING: Failure lo secure rvorkers' cotnpensation coverage and ancl civil fines up lo one hundred thousand dollars ($100.000).tltc Section .1076 of the labor Code. r)oto. l-2O *ry I hcreby affirrn under penalty of pcrjury lam 1'rrovision 9 (conrnrcncing w'ith 7000) of Division 3 of the llusiness and Professions Code. and my liccnse is in full forcc [,iccnse ('lass:37 72f :{3 r)nrc: i /' ZO 'ry I hereby affirm under penalty of perjury that issued (Sec. 3097. Civ. C.). Lender's Nanre: isa lending ag,cncv the pcrfonnance of the rvork fior s'hich this pctrnit is Lender's Address: _ APPLI(]AN]' DE(:I,ARA'I'ION I lro'eby allinn under pcnalty of perjury one of lhe follorving declarations: Dcruolitiorr Pernrits-Asbestos Nolificatiort Fcdcral ('l'itle 40. Pan6) -Required Letter of Notification --l certify that the federalregulations r errtor al applicable to this project. is ct'rrrect. I agrec to conrply u'ith all City and County reprcsentatives of this City and County to entef, upon thc Applicant or Agcnt Perrnitee Itt ,/tPo r)arc: /t -"o A, Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/VenVl ns u Iatio n I Roof Sheathins /L r/Z ilLI N '1TO/lfr Shear Wall /I Framinq lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif tl 7FINAL ?- fi3 /V07.O f u/o/ oy Certificate of Ociupancy Notes, Remarks, Etc. to