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BU!LDING. INSPECTOR RECORD t SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DET,CARATION I hocby aflirm undr pamlty of pcrjury that I m cxempt from the Contracto6' LiccN Law for the following r@n (Sa.7031.5 Businss ud Profession Codc): Any City q County which rcquirs a pmit to co$trucl. alt6. improva dernolish or repair my structuc. prior to its issuacc. also rcquirs thc applicilt for such pemit to filc a signed statmcnt that hâ‚¬ or shc b licffed pmumt to lhc provisions of thc Contractor's Licmscd law (Chapts 9. Commocing wilh SEtion 7000 of Division 3 of thc BNins ild Profsiorc Codc) or thar hc or shc is crmpt thcefrom od thc basis for lhc allcged cxmplion. Any violation of Sfirion 70.11.5 by anv applicantforapennilsubj6tsthe applicanttoacivilpenahyofnotmorethantivchundrcddollrs($500). _ _1. as o\!'ner of the propreny. or my employees \r'ith \!'ages as their sole compensation. s'ill do the rvork and the structuâ‚¬ is not intcnded or offered for sale (Sec.7044. Business and Professions Code: The Contraclor's l-icense [.au' does not apply to an orvner of the property rvho builds or improves thereon. and rvho does such wo* himself or herself or through his or her orvn employees. providd that such improvonents ate not intended or offered for sale. lf. horvever. the huilding or improvernent is sold u,ilhin one year of cornpletion, the Owner Builder will have the burden of proving th.t he or she did not lmild or improve the propoly for the purpose of salc). __-1. as owner of the properly. am exclusively contracting rvith licensed conlractorc to conslruct the pro.iect (Sec. 7044. Business and hofession Code: The Contraclor's l,icense l-arv cloes not apply to an o$,ner of propcrty rvho builds or irnproves thereon. and rvho contracts for such projects rvith a Contractor(s) licensed pursuant to the (-onlractor's l.icense l.as'). -l am exempt under Section-- . B. & P.C. for this reason. Owner:___ \},ORKERS' CONI PENSA'tION DE(:LARA'tION I hcrcby affrrm under penalty of pojury one of the follorving declarations: --l have and rvill maintain a Certificate of Consent to Self-lnsure for workets' compensation. as provided for by Section 3700 of the Labor Code. for the perfonnance of the rvork for rvhich the permit is issued. _-l have and rvill maintain rvorkers' compensation insurance. as required by Section -1700 of the Labor Code. for the perfonnance of ___l cerril-v that in the perforrnance of the rvork for rvhich this permit is issued. I shall not ernploy any person in any manner so astobecomesubjecttothervorkers'cornpensationlarvsofCalifornia.andagreethatiflshouldbecomesubjecttolhe n'orkers' compensation provisions of Section -1700 o[the Labor Code. I shall. forthrvith cornply rvith thosc provisions. WARNING: Failure to secure workers' compensation coverage is unlas'ful. and shall subject an crnployer to criminal penalties and civil fines up to one hundred thousand dollars ($100.000). in addition to the cost of compensation. damages as provided for the #;T'4"1";"lf' :-;"", n== ===,, I hereby affirm under penalry of perjury that I am licensal *,,t* p"*'ttt"" "f Clrapter 9 (commencing rvith Section 7000) of Division l of the Business and Professions Code. and rny license is in full florce and effect. !D License Number: t lL I o?.rn d2.I -icc:rtse oarc,l YO\l 4| (lontrnctor'-L CONS'I'RUCTION LENDING AGENC}' I hmby affim unds penalty ofpctjury thu thae is a construaion lending agcncy for thc pofomnncc ofthc $ork for ufiich this pennit is issued (Se'c. 3097. Civ. C.). Lender's Name: Lender's Ad&ess: APPLICAN'T DECLARA'I'ION I hercby aftirm under penalty of per.iury one of the follou,ing declarations: I)enrolition Perrnits-Asbestos Notification Federal Regulations (Title 40, Par16) -_--Required Letter of Notification ^ --l cqriry that the fedoal regulations rcguding mbetos removal re not applicable to this prcjct. Wn* r^^rl have red this applicarion ed srarc that the abore infomation is corcct. I agrc to @mply with all cityand County ordinancc md State lanvs rclating to building construction. ud hqebyauthorize rqrffitativc of this City and Countyto mtd uponthc abovc motioned prcpeny for impction purpos. Applicant or Agent Signature: L-I)nte: -ll-U)A I I l'erntiteename(printl: K ftr N)9y CInAY+ t Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloor/VenUl nsu lation Roof Sheathinq Shear Wall Framing lnsu lation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif I FINAL rc Certificate of Notes, Remarks, Etc + Dnte:__ -) lAA.rr,tYl,/a)