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BUILDING. INSPECTOR RECORD SITE.WORK DATE !D/SIG.COMMENTS OWNER BUILDER DELCARA'I'ION I hoeby aflirm undr peulty of Jrcrjury that I m exempt fiom the ContractoE' Licqs tnw for thc following rcen (56.7031.5 Busins and Profsion Code): Any City or Coutrty which rcquira a pomit to construct. alto. improva dcrnolish or rtpair my structurc. prior to its issumce. also requirs the applicilt for such pemit to file a signcd statanot that he or she is licoscd pwant to thc prcvisio$ of thc Conlractor's Liccnscd tarv (Chapts 9. Comencing with S{tion 7000 of Division 3 8f thc Busines md Prcfsions Codc) or that hc or shc is cxcmpt thqcfrom od the basis for thc alleged crmption. Any l iolstion of Scdion 70-11.5 by any applicantforapmnitsubjatsthc applicanttoacivilpenaltyofnotmorethefivchundrcddollrs($500). __1. as o\r'ner of the property. or my etnployees with wages as their sole compensation. rvilldo the u'ork and the structure is not intended or offered for salc (Sec.7044. Business and Professions Code: The Contractor's License Law does not apply to an orvner of the propa1y rvho builds or improves thermn. and rvho does such rvork hirnself or herself or through his or her orvn employees. provided that such improvonents are not intended or offered for sale. lf, horvever. the building or improvement is sold within one ),ear of complaion. the Orvner Builder rvill have the burden of proving tha he or she did not build or improve the propory for the purpose of sale). -1. as o\\'ner of the properly. am exclusively contracting u'ith licensed contraclors lo construct the project (Sec. 7044. Bu.siness and hofession Cocle: The Contraclor's l,icense Law does not apply to an owner of property w'ho builds or irnproves thereon. and rvho contracts for such projects rvith a Contracto(s) licensed pursuant to the Contractor's License Larv). _l am exempt under Section- __ . B. & P.C. for this reason. WORKERS' (]OI\T PENSA'I'ION DE(]LAITA'I'ION I hcrcby allirrn urtdcr pcnalty of pcriury ortc oIthc follou'ing dcclarations: -l have zurd rvill rnaintain a Certificate of Consent to Self-lnsure for lvorkers' compensation. as provided for by Scction 3700 of the Labor Code. for the perfonnance of the work for which the pennit is issued. -l have and rvill rnaintain rvorkers' cornpensalion insurance. as required by Section 3700 of the Labor Code. for the perfonnance of the work for rvhich this pennit is issued. My workers' compensaticln insurance carrier and policy number are: Carrier:_ l'trlicy Nurnbcr:Exoires: -l cerrify that in the pcrforrnancc of the rvork for rvhich this permit is issued. I shall not employ any person in any manner so ,ls to become subject to the rvorkers'compensation lau's of California. and agree that if I should bccome subject to the rvorkers' compensation provisions of Section -i700 of the l-abor Code. I shall. forths'ith comply u'ith those provisions. WARNIN(i: Failure to sccure rvorkers' compensation coverag,e is unlas'ful. and shall subject civil lines up to one hundred thousand clollars ($100.000). in addition to as provided for the Se<tion 1076 of the l-abor Code. interest and attorney's fees. DECLARATION I hereby affinn undcr penalty of perjury that I zun licensed under provision of Chapto 9 (comrnencing with Section 7000) of Division 3 of the Business and Professions Code. and my license is in full force and effect. License Class:- Dnte:_ f ina-c a @ I heeby allirm undu pclslty of pqjury thst thqe is a construction lcnding agocy for thc pofommce of thc work for which lhis pennit is issued (S(. 3097, Civ. C.). Lmds's Name: l.endcr's Arldrcss: APPLICANT DECLARATION I herelry alfinn under pcnalty of pcrjury one of the follos'ing declarations: Dernolition Perrnits-Asbcstos Notification Federal Regulations (Title 40. Pzur6) -Required l-etter of Notification _l certify that the Heralregulations regarding asbestos removal are not applicable to this project. __ I corify thal I have read this application and state that the above infonnation is I agroe to cornply rvith all City and County ordinances and State l-arvs relating to building of this City and County to enter upon the above mentioned property for inspection Dare: / l- 5- (, A;tplicarrl or Agerrt Pcrnrilee nanrc (prilrt ): Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/Ve nUI n su lation Roof Sheathinq Shear Wall Framing lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif I .A I .J, A ,l /1 ,A .^*/ FINAL iHl6l l7 (16F1(/2,'! 5rJ Certificate of Occu Notes, Remarks, Etc. to crirrrinal gxnalties and ('onlraclor: