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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION I heeby aflirm undr pcralty of perjury thd I m crmpt fiom thc (bntnclo6' Licemc Larv for the following rffin (Se.70-l1.5 Busin6s and Profesion Code): Any City or County which requirc a pernit to construct. ahc. improve. denolish or rcpair uy structue. prior to its isuucc. also requirs the applicut for such pemit to filc a signcd statmot lhat he or shc b lic$cd prcuarl to the Eovisions of thc Contractor's Licenscd Law (Chapts 9. Commencing with Setion 7000 of Division 3 of thc Busintss md Professiotrs Code) or that hc or shc is cxcmpt thcefrom ild thc b6is for thc alleged exonption. Any violation ofsction 70-3 I .5 by an) applicantforapernitsubjEtsthe applicottoacivilpcnaltyofnotmorcth.nfivehundrcddollus($500). --1. as owner of the propcrty. or rny ernployees with rvages as their sole compensation. rvilldo the rvork and the struclure is not intended or offered for sale (Sec.7M4. Business and hofessions Code: l-he Contractor's l.icense Larv does not apply to an ou'ner of the properry rvho builds or improves thereon. and rvho does such rvort hinrself or herself or through his or her own employees. provided that suclr improvanents are not intended or offered for sale. lf. horvever. the building or improvement is sold within one year of complaion. the Or*ner Builder rvill have the burden of proving that he or she did not build or improve the propoty for the purposâ‚¬ of sale). -1. as owner of the propefly. am exclusively contracting rvith licensed contractors to corr.struct the projecl (Sec. 7044. Business and Profission Code: The Contractor's License Lau' does nol apply to an owner of property u'ho builds or improves thereon. and rvho contracts for such projects with a Contractor(s) licensed pursuant to the Contractor's License l.aw). -l arn exempt under Scction- Dele: -. B. & P.C. for this reason. ()rr rtcr: \\'()RK Errs' ('()Nr PENjSA'r roN l)ll('l,Att^'t'toN foIlou ing tlcclaratiotts:I hereby alTirm under penalty of po'jury one of the --_l have and rvill maintain a Certil'icate of Consent to Self-lnsure for workers' conlpensation. as provided for by Section -1700 of the Labor Code. for the po'fonnance of the rvork for rvhich the pcrrnit is issued. _ I havc and the u'ork ftrr rvill rnaintain rvorkcrs'3700 of the l-abor Code. for the perfomrance of and policy number are: sl ('an'icr: = - fo -r+oLo t.\Drres:Policv Number:o s- a' __ I cenify that in the performance of the work for s'hich this permit is issued. I shall not employ any person in any manner so as to bc-come subje<t to the workers' cornpensation law's of Califonria. and agrc.e that if I should bccome subject to the provisions of Section .1700 of the Latxrr Code. I shall. forthrvith cornply rvith those prcr,isions.rvorkers' cornpcnsation WARNING: [;ailure to secure rvorkers' cornpensation coverage is unlau'ful. and shall an anployer to criminal penalties and civil fines up to one hundred thousand dollars ($100.000). in addition cost of dalnages as provided for the Section .3076 of the Lakrr interest and attorncy's,\L' I hereby alhrm under penalty of pcrjury that I arn license<l 9 with Settion 7000) of Division .3 of the Business and Prolcssions ('ode, and my license is in full force and efl""Lt. l-icense.-,rr* C3CT u,,u,--t l:tl'llI- (z I hereby affirm under Srenalty of pojury that there a construclion lending agency for the perfonrrance of the work for u'hich this perrnit is issued (Sec. 3097. Civ. C.). l.ender's Narne: Lender's Address: APPLICANT DECLARA'I'ION I hâ‚¬reby aflinn under penalty of perjury one of the follorving declarations: Demolition Perrnits-Asbestos Notification Federal Regulations ('title 40. Parr6) -Required Letter of Notification __l cc'r1ify that the federalregulations regarding asbcstos rernoval are not applicable to this prnject. I colify that I have reacl this application and w'ith all City and ('ounty ordinanccs and State Larvs relating to building and Counly to enter upon the above mentioned property for inspection r)are: ( /L,t7Applicant rlr Agent Signnture:_ I'el'rnitcc !riunc (llrint): atnve I Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/Ve nul n s u latio n , Roof Sheathing tl trltq )r4/&- fr Shear Wall ll -;- Framing lnsu Iation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif Ir .l FINAL tr lrfr1lr fvryr Certificate of Occupancy vt t Notes, Remarks, Etc. .*.r.,o,-(ffi Y \ wnfi,