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c BUILDING- INSPECTOR RECORD SITE WORK DATE !D/SIG.COMMENTS ()WNE,R B I.]II,DER I)EI,CARA'I'ION I hereby affirnr under penalty of pertury that I am exempt from the Cbntractors' I-icense [-aw for the following rean (Scc.7031.5 Busincss and Prolbssion Codc): Any City or County which requircs a pcrmit to construct, alter, irnprove, demolish or rcpair any slructure, prior to its issuance. also requires the applicant for such permit to file a signed statemenl that he or she is licensed pursuanl to lhc pnrvisions ol' thc Conlraclor's Licensed law (Chapter 9. Commencing with Section 7000 of Division 3 ol'the Bu.siness and Professions Code) or that hc or she is exempt therefrom arxl tlre basis tbr thc alleged exenrption. Any violation of Sectircn 7031 .5 by any applicant for a perrnit subjects thc applicant to a civilpenaltyof not nnre than five hundred dollars ($5001. _1. a.s owner ol'thc property, or my cmployces with wagcs as lheir solc compcnsation, will do thc work and the stnrcture is ml intemlcd or oflercd for salc (Scc'.7OC+, Business and Profcssions Code: The Contractor's Licensc l-aw tlocs not apply lo an owner of the pnrperty who huilds or in{rorcs thcrmn, arxl who dcrcs such work himself or hcrself or through his or her own employees, provided that such improvcrnents are rnt intendcd or ollerud for sale. ll, however, the building or improvennnt is soH within one )â‚¬ar of conqrhtion, thc Owner Builder will have the burden of pnrving that he or she tlid not build or improve the propcrry for the purposc of sale). -1. ns owner of the property, amcxclusively contracting with licensed L^onlracloni to construcl the project (Scc. 7(X4. Business and Pnrlbssi<xr Code: The Conlractor's Licerrse Law does not apply to an owner of property who builds or inrproves thereon. ancl who contracls for such projects with a Contractor(s) licensed pursuanl lo the Contraclor's Liccnse Law). _l anrexempt under Section_, B. & P.C. lirr this reason. I)ale: WOR KI.I,RS' COM|'!:NSATION DECLARATION I hcrcby allirm undcr penahy of pcrjury onc of the tbllowing declarations: _lhaveandwill nraintainaCertificateofConsenttoSelf-lnsureforworkers'conrpensation,as pr<lvidedforhySection3T00ofthe Labor Codc, for thc pcrformancc of the work lbr which thc permit is issucd. _l have and will nraintain workers' compensation insurance, as required by Sect ion 3700 of the Labor Code, for lhe performance of thc work tbr which this ;rcrmit is issued. My workers' compcnsation insuruncc carricr arxl policy numhcr are: Policy Number: Expires: _l ccrtity lhat in the pcrformance of the work for which this permit is issucd, I shall not employ any lrcrson in any manner so as to bccorne subject to the workcrs' comlrcnsation laws of California. and agree that if I stnuld bccomc subject to the workers' comlrcnsation provisions of Section 3700 of the Labor Code, I shall, forthwith comply with thosc provisi<lns. WARNING: Fuilurc to secure workers'comlrcnsation covcragc is unlawful, arul shall subject an cmployer to criminal Srenalties and civil fines up to onc hundred thousand dollars ($l00,Un). in addition to the cost of compensation. damages as provided for the. Section 3076 of the Labor Code, interest and attorrry's fees. f t...,.. LICENSED CONTRA(:TOR DECLARATION I hcrcby allirm undc'r pcnalty of Srcrjury that I am licenscd under provision ol'Chaptcr 9 (cornrnencing with Section 7m0) of Division 3 of thc Busincss and Professions Code, and nry licensc is in full forcc and cffcct. I License Class: License Number: Date:I CONSTRI,'CTION I,I.:NI)I NG AGT:NCY I hercby atlirm under Jrenaltyof perjury that there is a construction hnding agerlcy frrr the perfornrar*-e of the work fbr which this permit is issucd (.Scc. 3097, Civ. C.). [,cndcr's Namc: l-cndcr's Addrcss: APPLICANT DECLARATION I lrrcby affrm under penalty of perjury one of the following declarations: Denyolition Permits-Asbestos Notification Federal Regulations (Title 40, Part6) _Requiretl lrtter of Notifrcation _l certity that the federal regulations regarding asbeslos renroval are not applicable to this project. _l certify that I havc read this application arxl state that lhc abovc information is correcl. I agree to comply with all City antl County ordinances and State Laws relating to building constructiorL arxl hereby autlnrize representalives of this City and County to enter upon the above mcntioncd propcrty for inspection purposes. Applicunt or Agent Date:_ Permltee name (prlnt): - Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf I oor/Ve nUI n su Iatio n Roof Sheathinq Shear Wall Framinq Insulation/Enerov Drvwall Ext./lnt. Lath Brown Coat JVlasonrv Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Fina! Report Flood Zone Certif. FINAL Certificate of Occupancy Notes, Remarks, Etc. tJ rC>