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BUILDING- INSPECTOR RECORD SITE-WORK DATE ID/SIG COMMENTS OWNER BUTLDER DELCARATION I hcrcby aflirm undcr rcnalty of lErjury that I m cxcmpt frcm lhc CoNractoN' Licen* [:w tbr thc following rc&sn (Scc.7031.5 Busincss and Prcfcssion Codc): Any City or Couily which requircs a pmit to construcl. altcl irrprove. dcmlish or rcJnir my slruclurc. prior to its issuancc. alm rcquircs thc applicant for such Jrcrmit to lih a signcd statcmnt that hc or she is licensd puEuant to lhc pmvisions of thc Contractor's Licenscd I:w (Chapter 9. Commercing with Section 7000 of Division 3 of the Busiress ond Pmfcssions Codc) or thut hc or shc is cxcmpt thscfrom and thc basis for thc allcgcd cxcmption. Any violation of Sstion 703 1.5 by any applicant for a Ennit subjets thc applicant lo ! civil pcnalty of not mrc than five hundrcd dollus ($500). -1. as owncr of thc propcrly, or my cmployces with wagcs as thcir solc conrlrcnsation. will tlo thc work ard the structurc is not intendcd or offcrcd lbr salc (Scc.7044. Business and hofcssions Codc: Thc Contractor's Liccnsc Lrw docs not apply to an owncr of thc proJrcrty who builds or improvcs thercrrrr. and who docs such work himsclf or hcrsclf or through his or her own crnpklyccs. providcd that such improvcnrcnts arc rrrt intcndcd or ollbrcd ltlr salc. lf, howcvcr. thc building or impr)vcnrcnt is sold within onc )car of contplction. thc Owncr lluildcr will have thc burdcn of proving lhal hc or shc did not build or improvc thc propcrty ftrr thc purposcof sale). -1. as owncr of thc propcrty, anr cxclusivcly contracting with liccnscd conlractors lo conslruct thc projcct (Scc. 7044. Busincss and ftof'cssion Code: The Contraclor's Liccnse Law docs nol apply to an owncr of property who builds or improves thereon. and who conlracts for such projects with a Contractor(s) licenscd pursuant to the Contractor's Licensc t aw). -IamcxcmptunderScction-.B.&P.C.forthisrcason.Dale: Owner:_ WORKF.RS' COMPF.NSATION DECLARATION I hcrcby alfirm undcr penalty of pcrjury one of thc following dcclarations: -l have and will maintain a Ccrtificatc of Conscnt to Sclf-lnsurc fbr workcrs' compcnsation. as provided for by Section 3700 of thc I-abor Codc. ltlr lhc pcrformancc of thc work filr which thc pcrmit i.s issucd. -l havc and will maintain workers' compensalion insurancc. as rcquircd by Scct ion 37fi) of thc Labor Codc, for thc pcrformancc of lhc work lor which is contJrcnsation insurancc carricr and Jxrlicy nuntbcr arc: e /zs /r,I Policy o 6 -l ccrtify lhill in thc pcrformncc of thc work for which this fErmit is issucd, I shall not cmploy any pcrson in any rmnncr s as Io tEorc subjccl to thc workcrs' compcnsation laws of Califomia, and agrc Ihat if I should becom subFct to thc -workcrs'comJrcnsrtionprcvisionsofScction3T00ofthetiborCode,lstull.forthwilhcomplywilhthosprovisions. WARNING: Failurc lo scurc workcN'@mlEnsation covcragc is unlawirl. and shall subjcrt an employcr to simiml Fmltics and civil fincs up to onc hundrcd thousand dollm (SI00.000). in addition to thc co$ of comlrcnslion. darogcs as provided for the Scction 3076 l;tbor Codc. intcrcst and altorney'sozo z/ DECI ARATION I hcrcby affirrn undcr pcnalty of pcrjury that I arn liccnsed undcr provision of Chaptcr 9 (commcncing with Scction 7000) of Division 3 of thc Busincss and Profcssions Codc, and my liccnsc is in full forcc iurd cffcct. Liccnscrr^r.' eeq LiccnseNumbcr:? 5e/ /6 zoz/Z W I hcrcby affum under [Enslly of pcrjury that thcrc is a construction lcnding agcrcy for thc prformrcc of lhc work for which thk lrcrmii is issued (Se. 3097, Civ. C.). kndcr's Nam: Lcndcr's Addrcss: APPI ICANT DECLARATION I hcrcby affrnn undcr pcnalty of perjury one of thc following dcclarations: Dcnrolition Pcrmits-Asbcstos Notification Fcderal Rcgulations (Titlc 40, Part6) -Rcquired [-ettcr of Notification -l ccrtity that thc fedcralrcgulations rcgarding asbcstos rcmovalarc not applicablc to this projcct. statc that thc uhrvc infonnation is corrccl. I agrcc to cornply with all City and County to entcr upon thc ahovc rncntiorrcd propcrty for Applicant or Agerrt hercby authorizc rcprcsentatives of this City and z z/ Set Backs Forms/Stee!/Holdowns Erection Pads UFER Ground SLAB Floor S u bf loor/Ve nt/l n su latio n Roof Sheathing gl -?-t4 lZJ-Z a Shear Wall Framing lnsulatio nlEnergy Drywall Ext./lnt. Lath Brown Coat lt/asonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif FINAL u-15-Z{/A_(s Nc /4rg,tT zr7 Certificate of Occupancy Notes, Remarks, Etc.>_ v /'- o Exnircs: Applicant: Permitee nanle (print):_