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!NSPECTOR RECORD SITE-WORK DATE !D/SIG.COMMENTS OWNER BI.II LDER DELCARATION I herebl alTinn under penaltl' of periury that I anr exempt ftrrm the Contractors' l-icense l-aw for the follorving reason (Sec.70.11..5 Business and Profession ('ode): Any City or County which requires a perrnit to construct. alter. improve. dernolish or repair any structure. prior to its issuance. also requires the applicant for such pennit to file a signed statement that he or she is licensed pursuant to the provisions of the ('ontmctor's l.icensed l.arv (Chapter 9. Comrnencing rvith Section 7000 of Division .1 of the Business and Professions Code) or that he or she is exenrpt therefi'orn and the basis for the alleged exemption. Any violation of Section 7031 .5 by any applicant for a permit sub.iects the applicant lo a civil penalty of not more than five hundred dollars t$,-500). N! t. .r o\!'ner of rhe property. or my enrployecs rvith rvages as rheir sole cornpensation. will do the rvork and the structure is nor intended or offbred for sale (Sec.7044. Business and Professions ('ode: The Contractor's [.icense l-arv does not apply to an olvner of the propety rvho builrts or improves thereon. and rvho does such rvork himself or herself or through his or her ou,n employees. provided that such improvonents are nol intended or offered for sale. lf. hos,o'er. the building or improvonent is sold within one yâ‚¬r of complaion. the Os'ner Builder s'ill have the burden of proving that he or she drd not build or im;nove the properw for the purpose of sale). ro l. a. owner of the property.am exclusively contracting u'ith licensed conmctors to construct rhe project (Sec. 7044. Business and Profession ('ode: The Contractor's License l.arv does not apply to an owner of property rvho builds or improves thereon. and rvho contracts for such projects with a Contractor(s) licensed pursuant to the Contractor's l,icense Law). No I a,, exempt uncler Section - _ _. B. & P.C. for this reason. \I'OR.KF'RS' COMPFNS TTION NFCT ^ RATION I hereby affirm under penalry of perjury one of the following declarations: !! f n.u. and w'ill maintain a Certificate of ('onsent to Self-tnsure for rvorkers' compensation. as provided for by Seoion -1700 of the Labor Code. for the performance of the work for rvhich the permit is issued. YES __-l have and rvill rnaintain workem' compensation insurance. as required by Section 3700 of the [,abor Code. for the pcrformance of the work for which this pennit is issued. My workers' compensation insurance carrier and policy number are: STATE FUNDCarrier:_ _ 9278377 0c120t2021 NO _l cenifu that in the performance of the u,ork for rvhich this permit is issued. I shall not employ any person in any manncr so as to become subject to the rvorkers' comrrcnsation laws of California. and agree that if I should become subject to the workcrs' comFrcnsation provisions of Section 3700 of the Labor Code. I shall. forthwith comply with those provisions.. W'ARNIN(i: I;ailure to secure worters' conrpensalion coverag,e is unlawful. and shall suh.iect an ernployer to crirninal penalties and civil fines up lo one hundred thousand dollars ($100.000). in addition to the cost of compensation. damages as provided for thc Section 3076 of the l-abor ('txle. interest and attomey's fees. LI('T'NST'D ('ON'TRACTOR NTCI ARATION I hereby alTirm under penalty of perjury that I am licensed under provision of Chapter Q (commencing u,ith Section 7000) of Division 3 of lhe Business and Professions Code. and rnv license is in full force and effect. B.C-30.C-2 l-icense ('lass:2129/;9 License Number C()NS'[RI.I('TTON I .FNNING .t(:I.'N('Y I hereby af inn undcr penalty of periury that there is a construction lending agency for the perfonnance of the work forrvhich this grerrnit is issued 1!isq. .1097. ('ir,. ('.). l-encler's Narne: l-endcr's Atlclress: APPI I('I.NT NFCI {,R,ATION I herebv allinn under penalt_y of perlury one of the followrng declarations I)entolrtton Pernuts-Asbestos Nottlicalton Federal Regulalrons (Trtle 40. Part6) !9 Required l.etterof Notification tlt , ceflify thar the federal regulations regarcling asbestm removal are not applicable to this pro.iect. YES I cefli$ that I have read this application and state that the above information is correct. I agree to comply with all City and County ordinances and State [as's relating lo building construction. and hereby authorizc representatives of this City and County to enter upon the above menlioned property for inspection purposes. Reroof t r4l Roof (Diaphragm Sheathing/Frame)(LTIU Dkwi ( Structural Final '7 l9t1-\l-rtP91j g Plumbing I Under Floor I Under Slab Rough Shower Pan / Tub Test Water Service Sewer / Sewer Cap Gas Air Pressure Test Plumbing Final Electrical Service (Meter I Panel) Grounding / Bonding Rough Electrical Final Mechanical Gas Air Pressure Test Rough Piping (HW, CW, etc.) Exhaust Ducts N/echanical Final Notes, Remarks, Etc.