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BUILD!NG. INSPECTOR RECORD SITE.WORK DATE iD/SIG.COMMENTS OWNER BUILDER DELCARATION I hocby afiirm unde pemlty of perjury that I m exempt ftom thc Cootmclon' Licqs taw for thc follo*ing rwn (.!e.7031.5 ' Buinss ud Prcfcsion Codc): Any City or Couoty which rcquira a pcmit to @nstruct, alt6, improve, dmolish or rcpair my. . structw, prior to its issumcc. also rcquic thc spplicut for such pemit to filc a signed statmot that lt or slrc b lic@sâ‚¬d p6umt to thc provisioE of thc Contractor's Liccnscd taw (Chapta 9. Comcncing with Setion 7000 of Division 3 of thc Busins an<! Profsions Code) or that hc or she b cxcmpt thscfrom ild thc besis for thc allcgcd crmplion. Any violation of Setion 70-l1.5 by 8ny applicantforapamitsubjetsthc applicanltoacivilpcmltyofnotmorcthilfivchundrcddollss($500). _1. u ownr of the profEaty. or my cmployco with wag6 as their mlc composation. will do the wod< and thc slructrc t mt intadcd or ofrercd for ulc (Se.7M4, Bwins ad Profssioro Codc: Thc Conlractor's Licffi Law do6 not apply to il o\wq of thc Fopqty who builds or imprcve th@n. od who do6 such uort himsclf or hwlf or thrcugh his or hr om mploycc. providcd that such improvsrcils rc not intqdcd or ofcrcd for sh. If. howqq. thc buiHing or improl md is sH within onc ya ofcornpktion. thc Ovmq Buikla will harc thc hrdm ofprcving tha hc or she dil mt build or improvc thc propqry for rhc p[pos of sle). _1. sownqofthc prcpaty. muclusivcly contracting with licosed contractoE to conslrucr thc prcjâ‚¬t (SG. 7M4. Busins and Proftssim Code: Thc Contractor's Licmsc Law doc not apply to s ownd ofprcpcny who builds or imprcvcs lhs@n. and u,ho contmcts for such projats with a ContBcto(s) liccnsâ‚¬d puEuat to thc Conlractor's Licw [anv). I m GxcmDt unds Sstion-, B. & P.C. for this rc6on. l).r I r.'Owner: I hereby alTirm under penalty of po'jury one of the follorving _l have and rvill maintain a Certifrcate of Consent to Self-lnsure for workers' compensation, as provided for by Section -3700 of the Labor Code. for the performance of the work for which the perrnit is issued. 3700 of the Labor Code. for the performance of_l havc and the rvork for and policy numkr are: s' Policy r,lpi.es, /r/go/ a) -l certify that in the performance of the work for rvhich this permit is issued. I shall not employ any person in any manner so :ls to become subject to the workers'compensation laws of California. and agree that workers' compensation provisions of Section 3700 of the Labor Code. I shall. forrhrvith if I should bccome subject to the comply with those provisions. WARNING: Failure to secure workers'is unlawful. and shall subject an employer to crirninal penalties and civil hnes up to one hundred thousand to the cost of compensation. damages as provided for the Section -1076 of the Labor Code. interest and fees. l)li('1,,\llA'l'lON I hereby affirm undcr penalty of perjury that I am licensed under provision of Chapter 9 (commcncing with Section 7000) of Division 3 of the Business and Professions Code. and my license is in full force and effect. q:zoa?c t License 7O ('ONSI'RU(' I'ION I,ENDIN(; A(;}:N( \' I hrcby affrm undo peralty of pcrjury that thrc is a consrucrion lading agocy for thc pofommcc of the *ork for which this pqmil b issued (Sec. 3097, Civ. C.). Lender's Name: I-ender's Address: APPLICANT DECLARATION I horby aflinn under penalty of perjury one of the following declarations: Dernolition Perrnits-Asbestos Notification Federal Regulations ('l'itle 40. Pafl6) -Required Letter of Notification _l certify that the Heral regulations regarding asbestos rcmoval are not applicable to this project. _l cerrify that I have read this application and state that the above information is corect. I agree to comply rvith all City and Ccunty ordinances and State Laws relating to above mentioned property for Applicnnt or Agent Pernrilec nnnrc construction. and hereby authorize representatives of this City and County to ent. /u" Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/Ve nUl n s u latio n Roof Sheathinq Shear Wall Framinq Insulation/Energy Drvwall Ext./!nt. Lath Brown Coat J\4asonrv Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif. I I FINAL t-il6llol LW000 -#w Certificate of Occupancy I Notes. Remarks, Etc. I ?.0 tA-- """, llft i l \,1-< h,aziqyl V- nLnAt\