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BUILDING. INSPECTOR RECORD SITE-WORK DATE ID/SIG.COMMENTS OWNER BUTLDER DELCARATION I hccby affm undo poalty of pcrjury thst I m exmpt ftom thc Contraclon' Licw law for thc folloving rmn (5*.7031.5 BBinss ild Profsion Codc): Atry City or Coufiy which requirc a po'mit to oGtruct, alta, improvc, danolish or rcpair ay structurq prior to its isuace, also rcquirs thc applicet for such pcfinit to filc a siSncd statcmt rha hc or slrc b liccnscd pwarl to thc fovisioE of thc Contractor's Liccnscd law (Chapt6 9, Comcncing with Sation 7000 of Division 3 of thc Buins md Prcfesions Code) or that he or she is cxcmpt thcefrom ad thc b6is for thc allcgcd cxopion. Any violatiotr of Serion 7031,5 by my applicantforapermitsubjetsthc applicilttoacivilpenaltyoftrotmorethilfivchundrcddollm($500). -1, os owner of the property, or my employees with wages as their sole compcnsation. willdo the work and thc structurc is not intended or offered for sale (Sec.7M4, Business and hofessions Code: The Contractor's Liceirse Law does not apply to an owncr of the property who builds or improves theron, and who does such work himself or herself or through his or her own cmployees, provided that such irnprovonents are not intended or offered for sale. I[, howc'/er. the building or improvemcnt is sold within one ]Ear of complaion, the Or,vner Builder will have the btrden of pnoving thd he or she did not build or improve the propcrty for the purpose of sale). _1. as owner of the property, arn exclusively contracting with licenscd contractors to construct the project (Sec. 7M4, tsusiness and hoftssion Code: The Contractor's License Law does not apply lo an owner of property who builds or improvcs thereon. and who contracts for such projects with a Contracto(s) licansed pursuant to the Contractor's Licensc t aw). _l am exempt under B.rcason. ,,,.,41u/[)\ DECLARATION I hereby affirm under penalty of perjury one of the following declarations: -l have and will maintain a Certificate of Consent to Self-lnsure for workers' compensation. rui provided for by Section 3700 of the Labor Code. for the performance of the work for which the perrnit is issued. -l have and will maintain workcrs' compcnsation insurance, as rquired by Section 3700 ofthe Iabor Code, for the performancc of the work for which this permit is issucd My workers' compensation insurance carrier and policy number are: Carrier: ., Policv Number: Exoires: _l cealiry thar in the prformance of the work for which this permit is issued. I shall not mploy my pmon in any mlirno $ 6tobeome subjettothcworkq'compqutionlamofCalifomia,ildagEthatiflshouldbsome subj*ttothc workm' ompsxation prcvisiom of Setion 3700 of the labor Codc. I slull. fonhwith @mply with tho* prcvisiom. WARNING: Failurc to sw workm' compensation covmgc is unlawful. ud shall subjer a oploya to qiminal pemltics md civil fines up to one hundrcd thousd dollm ($100.000). in addition to thc cost of compcmtion. damagc r providcd for rhc Section 3076 of the Labor Codc. interest and ,rr",4ll Uft \ I hereby affrrm under penalty of pcrjury that I am licensed 9 (cornmencing with Section 7000) of Division 3 of the Business and Professions Code. and my license is in full force and effect. License Class: Licensc Number: W I hercby affm undo pcnalty of pc{ury that th@ is a snstruclbn lcnding ag6cy for the pqfomcc of thc work for which this po'mh b issucd (Sc. 3097, Civ. C.). Lender's Name: Lender's Address: APPLICANT DECLAIIATION I hereby aflinn under penalty of perjury one of the following declarations: Dcrnolition Permits-Asbestos Notification Federal Regulations (Title 40. Par16) _Required Letter of Notification -l cqriry that thc fedoal rcgulatiom rcgsding cbctos rmoval uc oot spplicsblc lo this prcjel. -l cdiry that I havc rcad this application and statc thn thc abov. infomarion is cor61. I agrâ‚¬ to omply with all City ud County ordinancB ild State laws rclating to building congrucriorl ad h6cby authorirc rcp6atai(c of this City md Couty to 6tq upotrtq: above mentioned property for inspection Applicant or Agent Pernritec nAnre (print): ,,,",4lwlll Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloor/VenUl nsu lation ,l Roof Sheathing <(llclu Shear Wall t /I L-/ Framinq I Insu Iation/Energy Drnrvall Ext./!nt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif lt I FINAL Q.lnb,\ "i\, ?-, Certificate of Occu \-/ Notes, Remarks, Etc.v Contrrctor: /