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BU!LDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hseby affirm unds peralty of perjury that I m excmpt from the Contraclo6' Licorc liw for thc following rwn (Se.7031.5 llusinCs md Profeion Codc): Any City or County which require a pemit to construct. alto. improvq demolish or rgnir oy slruclue. pior to its issuance. also rcluirG the applicilt for such peflnit to filc a signed ststmcnt that he or shc is lictred puBumt to lhe provisions of the Contractor's Licenscd Larv (Chapts 9. Commcncing sith S(tion 7000 of Division -l of the Busines md ProfrcionsCode)orthalhcorsheisexcmptthqefromildthe basisforthe allegedexenption. AnyviolationofSctionT03l.5byany applicant for a pmnit subj(ts the applicant Io a civil penalty of not more thil live hundred dollils ($500). _-1, as owner of the propeny. or my employees with wages as their sole compensation. willdo the work and the struclure is not intended or offered for sale (Sec.7044. Business and Profcssions Code: 'l'he Contractor's l,icense Larv does not apply to an owncr of the propeiry rvho builds or improves thereon. and rvho does such \r'ork himself or herself or through his or her own employees. provided that such improvanents are not intendetl or offered for sale. I[, horve''rer. the building or improvement is sold within one ]ear of complaion. the Orvner Builder rvill have the burden of ;noving tha he or she did not build or improve the propoly for the purpose of sale). __1. as owner of the property. arn exclusively contracting with licensed contraclors to construct the project (Sec. 7044. Business and hoftxskrn Code: 'fhe Contractor's l-icense Larv does not apply to an owner of properly rvho builds or improves thereon. and rvho contracts for such projects rvith a Contractor{s) licensed pursuant to the Contractor's [,icense Larv). _l am exempt under Section_B. & P.C. for this reason. l)ntc:0rvner: w()ttK t.llls' ('oNt t't,tNsA't'tdN DECLARA'TION I hereby alTirrn under penalty of pojury one of the follorving declarations: _l have and lvill rnaintain a Cstificate of Consent to Self-lnsure for w'orkers' compensation. as provided for by Section 3700 of the Labor Code. for the po'formance of thc work for rvhich the permit is issued. [tl have and rvill rnaintain rvorkers' compensation insurance. as required by Section 3700 of the Labor Code. for the perfonnance of rvork for which this permit is issued.rvorkers' compensation insurance carrier and policy number are: ) l'>olicy Exoires: _ I certify that in the perforrnance of the w'ork for rvhich this perrnit is issued. I shall not ernploy any person in any nranner so .rs to become subject to the rvorkcrs' cornpensation la*'s of California. and agreâ‚¬ that if I should become subject to the s'orkâ‚¬rs' compensation provisions of Section 3700 of the Labor Code. I shall. forthu'ilh comply u'ith those provisions. WARNING: Failure to secure s'orkers' civil fines up to one hundred thousand coverage is unlarvful. and shall subject an employer to criminal penalties and in addition to the cost of for thc DECT.,ARATION I hereby aflirm under penalty of po.iury that I arn licensed under provision of Chapter 9 (comrnencing rvith Section 7000) of Division -3 of the Business and Professions Code, and my license is in full force and effect. F/.u,::':i Nurnber:-b. 7a(? c0NS t'RU("t't0N t,t,:Nt)tN(; A(;Il,N('\' I heeby affurn unda peralty of pcrjury that thqe b a construction ldding agmcy for thc pofonmce of thc rvork for rvhich this pqmit b issued (Sec. -i097. Civ. C.). Lender's Name: l.ender''s Acltlrcss: APPLICANT DECLARATION I herâ‚¬b,y affrrm under penalty of perjury one of the follorving declarations: Demolition Perrnits-Asbestos Notification Federal Regulations (Title 40. Pan6) -Required Letter of Notification -l cenify that the federal regulations regarding asbestos removalare not applicable to this project. above information is conect. I agree to comply rvith all City and County of this City and ('ounty to enler upon lhe above rnentioned propeity for Applicant or Agerrl l'ermitee nrnre ./rr^r",/ t'rclz Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/VenUI n s u latio n Roof Sheathing Shear Wall Framing lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat Itlasonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif FINAL t;ddata n /,<r,t ?/a5 zr) Certificate of Occu pancy Notes, Remarks, Etc. .",,*EPR{+U [29,)r/** Scction 1076 l.ahrr Cocle. interest and __--_ fE< ,-J