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t INSPECTOR RECORD SITE-WORK DATE !D/S!G COMMENTS OWNER BUILNER DELCARATION I hereby affirm under penalty of periury thal I anr exempt form the Conmclors' License Law for the follorving re.ason (Sec.70-11 .5 Business and Profession Code): Any City or County rvhich requires a permil to construct. alter. improve. dernolish or repair any struc1ure, prior to its issuance. also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant lo the provisions of lhe ('ontractor's Licensed Larv (Chapter Q. Cornrnencing with Section 7fiX) of Division .1 of the Business and Professions Code) or that he ff she is e!(empt therefrom and the basis for the alleged exemption. Any violation of Section 7031 .5 by any applicant for a pcrmit subiects the applicant to a civil penalty of not more than fir,e hundred dollars 1$-s00). No-t. ,* owner of the property. or my employees rvith rvages as their sole compensation. will do lhe work and the stnrcture is not inrende<l or offered for sale (Sec.7M4. Business and Professions Code: The Contractor's License law does not apply to an own6 of the foperty u,ho builds or imlnoves thereon. and who does such rvort himself or herelf or through his or her own employees. provided that such improvements:ue not intended or offered fcrr sale. lf. hos,ever. the building or improvemcnt is sold within one year of ccmrplaion. the Orvner Builder will have the burdcn of proving that he or she did not build or improve the propertv for the purpose of sale). NO I. a. owner of the ptoperty. am exclusively conh'acting rvith licensed contr?ctorr lo constnrct the project (Sec. 7044. Buiness and Profession ('ode: The ('ontractor's License l.arv does not apply to an owner of property who builds or improves thereon. and u,ho contracts for such prnjecls rvith a Contracto(s) licensed pumuanl to the Contractor's License Larv). No-l .* exempt under Seoion . B. & P.('. for this reason. }I'OR.K FRS' COM PT'N SATION DFCI A,R.ATION I hereby affirm under penalty of perjury one of the following declarations: No I h.r. anct will maintain a Cerlificare of ('onsent to Self-lnsure for rvorkers' compensation. as provided for by Se<tion -1700 of the l.abor ('ode. for the performance of the work for which the permit is issued. YES lhaveandrvill maintainworkerc'compensationinsumnce.as requiredbySectionlT00ofthel,aborCode.fortheperformanceofthe *,ort for u'hich this pcrmit is issued. My workers' compensation insurance carrier and policy number are: Travclerr Carrier: uB-3Rs812r &20-26-Gl'olicr Nrrrtther': 10to112021 F.xpires: NO I cerrify that in the perfrrnnance of the u'ork for s'hich this perrnit is issued. I shall not emplo)' any person in any manner so as to become suh.iect to the rvorkers' compensation larvs of ('alifornia. and alree lhat if I should become subiect to the workers' compensation provisions of Section .1700 of the l-abor Code. I shall. forthrvith cornply rvith those provisions.. WARNIN(i: Failtne lo securervorftets'compensation coverage is unlawfirl. and shall subiect an employertocriminal penaltiesand civil fines up to one hundred thousand dollars ($100.000). in addition to the cosl of compensation. damages as provided for the Section 3076 of the l.abor Ccxle. interest and attomey''s fees. LI('FNSTD ('ONTRACTOR NECI A]TATION I hereby afTirm under Srnalty of prjury that I am licensed under provision of Chapter Q (commencing rvith Section 7000) of Division .1 of the Business and Professions Code. and rny license is in full force and effect. c20 l.icense Class: 822171 l.icense Numher CONSTRTICTION I FNDING AGENCY I herehy alTirm under grenalty of grerlury that there is a construction lending agency for the performarce of the work for which this permit is issued (Sec. .1097. Civ. C.). lrnder's Name: l.ender's Address: APPI l(-ANT DF('L^ RATION I herebv affimr under penaltv of perluw one of the followrng declarattons l)enxll rtion Perntits-Ashestos Notitication Federal Regulatrons (Title 40. Part6) Nl Required l.etter of Notification YEs I cefliry that the federal regulations regarding asbestos removal are not applicable to this pro.iect. YES I ..,rifi, thar t have read this application and state that the abol'e information is correct. t agree to comply wirh all City and County ordinances and State las's relating to building corLstruction. and hereby authorize representatives of this City and County to entcr upon the above mentioned properly for inspection puryoses. Reroof Roof (Diaphragm Sheathing/Frame) Structural Final Plumbing Under FIoor 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 Mechanica! Gas Air Pressure Test Rough Piping (HW, CW, etc.).A Exhaust Ducts r.htt, bt ?{) bD Mechanical Final Ilaht Er,r6.I.-7 Notes, Remarks, Etc. I