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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcrcby al-frm undcr pnalty of frcrjury that I am cxcmpt from tlrc Contractors' Liccnsc [:w for the following rcason (Sec.7031.5 Business ard Profcssion Code): Any City or County which rcquires a permit to construct. ahcr, improve, dcmolish or rcpir any structurc. prior to its issuance. also rcquires the applicant fbr such pcrmit to frle a signcd st&tenrcnt thal hc or shc ls liccnscd pursuant to thc provisions of the Contractor's Licensed Law (Chaptcr 9, Commencing with Scction 7000 of Division 3 of thc Busincss and Profcssions Code) or that hc or shc is exempt therefrom and thc basls for thc allcgcd cxemption. Any violation of Scction 7031.5 by any applicant for a pcrmit subjccts thc applicant to a civil penalty of not morc than five hundrcd dollars ($500;. -1, as owncr of thc propcrty. or my employces with wagcs as thcir sole compcnsation. willdo the work and the strrrcturc is rnt intcndcd or otTcrcd for sale (Scc.7044. Business and Prolbssi<lns Code: The Contraclor's Licensc [:w does not apply to an owncr of the property who builds or improvcs thcrcon and who docs such work himself or herself or through his or her own employces. providcd that such improvcnrcnt.s are not intendcd or offcrcd for salc. lf. however, thc building or inprovcnrcnt is sold within one )rcar of completiott thc Owncr Buiklcr will have the burden of proving that trc or she did not build or improve thc proprty for thc purposc of sab). -1, as owncr of the pmpcrty, am cxclusively contracting with liccnscd contractors to conslruct thc prolct (Sec. 7W, Busircss and [lofcssion Codc: Thc Contractor's Licensc Law docs not apply lo an owncr of propcrty who builds or improvcs thcrcon. and who contracts for such pr<ljccts with a Contractor(s) liccnscd pursuant to the Contractor's Licensc [.aw). _l am exempt undcr Scct B. & P.C. for this reason. f 1., r... YQBf,EESIOMS$SAIIAN DECI.AEAtrON - I hcrcby affm undcr [rcnalty ofpcrjury ore ofthc following dEluarions: -l haw anC will roinlain a Ccnificate of Consnt to Self-lnsw for wrkqs' orpcnsation. ai provided for by Strtion 3700 of thc Labor Codc, for thc pcrforlrec of the work for which the pcmit is issued. k'4t n"t" "na *itt *intrin workcrs' @mpensation insurarcc, as rcquired by Sstion 3700 of lhc Labor Code, for lhc prfomre of I thc work f<rr which this --Xt;rkcrs' cornpcnsation insurance carricr and plicy number are: c *rr*, f z6[3/J- Expircs:r,/.r/z t fty*nify that in the pcrfortrulncc of the work for which rhis pcrmit is issued. I shall not cnrploy any Frerson in any manner so as to bccomc subjcct lo thc workers' compensation laws of California, and agrce that if I should bcconrc subject to ttrc workers' compensation provisions of Section 3700 of the latnr Code. I shall, forthwilh comply with those provisions. WARNING: Failurc to rrccurc workcrs' compcnsation covcragc civil fincs up to one hundrcd thousand dollars ($100.0ffi). in ls and shall subjcct an cmployer to crinrinal Jrcnaltics and o[ conrpcnsation. danragcs as providetl for thc Codc, intcrest and attorncy's t'ccs. Applicant: DECI ^ TIATION I hercby affirm under pcnalty of pcrjury that I am licenscd undcr provision of Chaptcr 9 (comnrcncing with Section 7000) of Division 3 of the Business and Profcssions Code, and my liccnsc is in full force and effect. I iccnsc ctorr, C-'ZO -Liccnsc o 2?f Z Contritctrlr:urr/t 4 c\ CONSI?UCTION LEIDING AGENCY I hcrcby allirm urdcr 1rnally of JErjury that th@ is r constructhn lcnding agcrcy for the 1uforrucc of the work for which this Jrcrmit is issct (Sc. 3097, Civ. C.). bndcr's Nam: l-cndcr's Addrcss: APPLICANT DECLARATION I hcrcby allinn undcr pcnalty of pcrjury one of thc following dcclarations: Dcmolition Permits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40. Part6) _Required lrtter of Notification I ccrtifv that lhe lAcertify that I have fcdcralrcgulations regarding asbcstos rcnnvalarc not applicablc to this projcct. rcad this application and state that with all City and County and County to enter upon thcordinances and Statc Laws rclating to abovc nrcntioncd propcrty for inspcction Tpplicant or Agent \Permitee name At Z( Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf Ioor/VenVI ns u latio n Roof Sheathing Shear Wall Framing lnsulation/Enerqv Drywall Ext./lnt. Lath Brown Coat lt/asonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif . I I tl ^u s7- FINAL lll ,l'u Dffwo / Certificate of Occupancy I Notes, Remarks, Etc \ / \ Rev. 0B-07-201 5 <';:;',,'vr{i