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BUILDING- INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BIJILDER DELCARATION I hcrcby affrm undcr Fnalty of Friury that I m cxcn$t frcm the Contrrctos' Liccn* lrw for thc following rorco(Sc.7031.! - Busincss and Pmfession Codc): Any City or County which rcquires a lrcmit to construct. altcr. improvc, dcmlish or rctEir ur' strcturc, prior lo its issumcc. also rcquircs thc applicant for such lrcrmit to filc I signcd stalcrcnt thrt he or slE is licenrcd pusuurt to thc Fovisions of the ContBctor's Lienrcd kw (Chsptcr 9. Commrcing vith Setion 70q) of Division 3 of the Busircss ud ProfesshnsCodc)orthathcorshciscxctr{,tthcrcftomandthcbasisfortheallcScdcrcmplion. Anyviolatkrnofssthn?03l.5by8ny applicant for a [rcrmit subjsts thc lpplicant to a civil pcnalty of not mrc lhm five hundrcd dollus ($500). l _1. as owner of thc pr)pcny. or my cnlpbyccs with wagcs as their solc cornpensation. willdo lhe work and the structure is rnt intcndcd or offcrcd frrr salc (Scc.7044. Busincss and Profcssions Codc: The Contractor's Liccnsc l;rw docs not apply to an owncr of thc proJrcrty who builds or irnprovcs thcrcon and who docs such wo* hinrelf or hcrsclf or through his or her own employccs. providcd that such irngnovcnrcnts arc not inlcndcrl orofTcrcd lbr salc If. howcvcr. ttrc building or improvcnrcnt is sold within one ycar of cornplction. thc Owner Buildcr will havc ttrc burdcn of proving that hc or shc did not buikl or improvc tlrc propcrty for thc purynsc of salc). -1. as owner of thc property, am cxclusivcly contracting with licenscd contraclors to construct the projctt (Sec. 7044. Busiltcss arxl Prrofession Codc: Thc Contractor's License Law does not apply lo Bn owncr of property who builds or improves thereon, and who conracts for such projccts with a Contractor(s) liccnsed pursuant to the Contractor's Liccnse Law). -IamexelnptundcrSc.ction-.B'&P.C.forthisrcason.Date:__Owner:_ WORKER^S' COM PENSATION DECLARATION I hcreby afllrm undcr pcnalty of pcrjury onc of thc following dcrlaratiorrs: _l have and will maintain a Certificatc of Conscnt to Sclf-lnsurc for workers' comgrcnsation. as povided for by Section 3700 of thc [:bor Codc, for thc performance of thc work for which thc pcrmit is issucd./v I have and will maintain workcrs' comlrcnsation insurancc, as rcquired by Section 3700 of the [:bor Codc, lbr thc performance of Gi work for which this Jrcrmit is issucrl. My workcrs' compensation insurance carricr and plicy number are: Ciuricr: lA!ry+ (,4. .^l Cora.^Uot Policy \.rct\s ?ct t/,lr- _l ccrtify that in thc ;rcrformance of the work for which this pennit is issued, I shall not ernploy any pcrson in any manner so as to bccomc subjcct lo thc workers' compensation laws of California, and agrce that if I should trc.corrc subject to the workers' compcnsation provisions of Scction 3700 of thc Latnr Code. I shall. f'orthwith comply with thosc provisions. WARNING: Failure to sccure workers' compensation covcragc is unlawful, and shall subjcct an employcr to criminal Jrenalties and civil fincs up to onc hundrcd thousand dollars ($100.000). in addition to thc cost of compcnsation. damages as providcd for thc Scction 3076 of thc latnr Codc, intercst and attorncy's fecs. Date:_AppllcanI LICENSED CONTRACTOR DT'CI.ARATION I hercby alhrm undcr pcnalty of perjury that I anr licenscd under provision of Chapter 9 (comrrrncing with Scction 7000) of Division 3 of thc Busincss and Professions Code. and my licensc is in full forcc and cffect. Liccnsc L-to Nunrbcr:roL?c# r3 CT W I hercby affim urdcr lEmlty of Frjury that thm is a consruction hndirg agcrcy for thc trrformc of thc work for which this pcrmit is issucd (Sc. 3097. Civ. C.). Lcndcr's Narnc: lrndcr's Addrcss: APPLICANT NECI ARATION I hcrctry affrrn undcr pcnalty of perjury onc of thc following dcclarations: Demolition Permits-Asbestos Notification Fcdcral Regulations (Title 40. Part6) _Required l*tter of Notification _l ccrtify that thc fcdcralrcgglations rcgarding asbcstos rcnnvalarc not applicable to this proi"ct. -4""rtitythar I havc rcad rhis application statc that the atnvc infornution is correct. I agrce to comply reprcsentativcs of this City with all City and Counly ordinances and State [:ws relating to constructioru and hcreby authorizc and County to cnter uJnn thc abovc rrrcntioncd propcrly for 1Applicant or Agent I)ernrilc.e nanre 2n* Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loo r/VenUI nsu latio n Roof Sheathinq Shear Wall Framing lnsulation/Enerqy Drywall Ext./lnt. Lath Brown Coat JVasonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif ll ^LL ilt F!NAL ()'(lo )/rvT 3t Certificate of Occupancv Notes, Remarks, Etc. Rev. 08-07-201 5 o"t", 1 I