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BUILDING. INSPECTOR RECORD SITE-WORK DATE ID/SIG.COMMENTS OWNER BUII,DER I'ELCARATION I hocby affum unde pcralty of perjury that I m cxempt frem thc Coilraclon' Licre law for the follorving rwn (56.7031.5 Businos md Profsion Codc): Any City or Counly rvhich rcquirs a perrnit to construct. altc. improre. donolish or rtpair uy slructurq prior to its isuilce. also rcquirs the applicet for such pcmit to filc a signcd slalmmt that hâ‚¬ or shc is licqsâ‚¬d pmualt to thc povisions of thc Contractor's Licmwd tarv (Chapts 9. Commcncing with Sction 7000 of Division 3 of thc Bruins md Prcfe$ions Code) or that hc or she is cxcmpt thqefrom and the b8is for thc alleged exonption. Any violation ofSec,tion 703 L5 by any applicantforapemitsubjatsthc applicanttoacivilpcnaltyofnotmorethmfivchundreddollrs($500). _- _1. as owner of the p'operty. or my employees with wag,es as their sole compensation. rvilldo the work and the struclure is not intended or offered for sale (Sec.7044. Business and hofessions Code: The Contractor's l,icense larv does not apply to an orvner of the properly rvho btrilds or improves thereon. and rvho does such work himself or herself or throug,h his or her orvn employees. provided that such imgnovanents are not intended or offered for sale. lf. hos'eter. the hrilding or improvement is sold rvilhin one year of completion. the Ouner Builder s'ill have the burden of proving that he or she did not btrild or improve the propaly for the purFnsc of sale). I. as o\\,ner of the properly. am exclusively contracting rvith licensed contractors to conslruct the project (Sec. 7M4. Business and Profession Co<te: 'l'he Contractor's License Larv does not apply lo an orvner of property who builds or improves thereon. and rvho contracts for such projects rvith a Contractorls) licensed pursuant to the Contractor's License Larv). t an exempt under Seclion-. B. & P.C. for this reason. Date:_Orr ner: WORKERS' COIIIPENSATION DECLARATION I hereby alhrm under penalty of petjury one of the follorving de'clarations: _l have and rvill maintain a Certificate of Consent to Self-lnsure for w'orkers' compensation. as provided for by Section -1700 of the Labor Code. for the perfonnance of the rvork for rvhich the perrnit is issued. -__l have and rvill rnaintain workers' compensation insurance. as required by Section 3700 of the Labor Code. for the performance of the rvork for which this permit is issued. My workers' compensation insurance cilrier and policy number are: {u *lD Nurnber:_-?r^z/td?tt _Expires:Z _ _l cerriS that in the performance of the w'ork flor rvhich this permit is issued. I shall nol etnploy any person in any tnanner so as to become subject to the w'orkers' comporsation laws of California. and agree that if I should becotne subject to the w,orkers' compensation provisions of Section 3700 of the L.abor Code. I shall. forthu'ith comply rvith those provisions. WARNING: Failure to secure rvorkers' compensation co!'erage is unlawful. and shall subjc'cl an onployer to criminal penalties and civil fines up to one hundrcd lhousand dollars ($100.000). in addition to the cosl of as provicled frlr the 3076 of the l.atxrr inlerest and attorney's fces. t,l(' llNS ltl) ('ON'l'ltA("1'OR l)li('1,,\R,\ l'l0N t hereby a(Tirm uncler penalty of perjury that t arn licensed under provision of Chapter 9 (contmencing rvith Seoion 7000) of Division .1 of the Business zurd Professions Code. and my license is in full force and effect. $::'-r,w, b -225_rB __ 7 contrrctor: l.iccrtsc Nurnlrer: CONS'l'RU("1'l(rN t,liN l)l NG i\GI'lN('\' I hcrcby affm undq pcralty of pcrjury that thqe is a corctructioo lcnding agacy for thc psfomocc of thc wrk for which this pqmh is issucd (Se. 3097, Civ. C.). lrnds's Nmc: - l.endcr's Addrcss: APPLI(]AN'T DEC LARA'IION I hotitry aflinn under penalty of perjury one of the follorvirrg declarations: Dernolition Perrnits-Asbestos Notification Federal Regulations ('titlc 40. Par16) -Requiled Letter of Notificatiorr _l certify that the lbderal regulations regarding asbestos rcmoval are not applicable to this projcct. _ I corify that I have read this application and state that thc alx'rve inlontration is correct. I rvith all City and County and County to enter upon theand l)ntc:/? Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/Ve nUl n s u latio n Roof Sheathins Shear Wall Framinq lnsulation/Energy Drywal Ext./lnt. Lath Brown Coat Masonrv Pool Fence T-Bar Handicap Req. Deputy Final Report Enqineer Final Report Flood Zone Certif. t I FINAL lt L@lt'i Dtrfio ,--#k9 Certificate of Occupancy ,t Notes, Remarks, Etc.t J,7 t t