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t INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNFR BUILDER DELC {RATION I hereby aflirm under penalty of grrjury that I am exempt form the Contractors' License l-aw for the following reason (Sec.70-11..5 Business and Profession Code): Any City or County rvhich requires a permit to construct. alter. improve. demolish or repair any structure. prior to its issuance. also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisiors of the Contractor's Licersed l.arv (Chapter 9. Commencing rvith Section 7000 of f)ivision -3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption Any violation of Section 70-11 .5 by any applicant for a pennit subiocts the applicant to a civil penalty of not more than fir'e hundred dollars (S500). No I. ,, owner of the property. or my employees u,ith rvages as their sole compensation. rvill do the rvort and the strucnre is not intended or offered for sale (Sec.7044. Business and Professions Code: The Contractor's l-icense larv does not apply to an owner of the propâ‚¬rty rvho builds or improves thereon. and who does such wort himself or henelf or through his or her ou,n employees. provided that such improvanents are not intended or offered fot sale. lf. however. the building or improvcment is sold rvithin one year of complaion. the Os'ner Builder rvill have the burden of proving that he or she did not build or improve dre properw for the frurpc,se of sale). !O l. ,. owner of the propery*. aln exclusivelv contraoing rvith licensed contractors to construct the pro.iect (Sec. 7044. Business and Pmfession Code: The Contractor's l.icense Lau,does not apply to an o$,ner of property rvho builds or improves thereon. and rvho contracts for such projects u'ith a ('ontracto(s) licensed pursuanl to the Contraclor's License Law). !o-t .rl exernpt uncler Section - - . B. & P.C. for this reason. W'ORKFRS' COM PENS{TION NF('I ARATION I herehy affirm under penalty of perjury one of the follos'ing declarations: *o t h.*'. and rvill maintain a Cerrificate of ('onsent to Self-lnsure for rvorkers' compensation. as provided for by Seoion .1700 of the l.atxrr Code. for the perfonnance of the work for rvhich the grermit is issued. YES lhaveands,ill maintainrvorkers'compensationinsurance.as requiredbySectionlT00ofthelaborCode.fortheperformanceofthe rvork for rvhich this pennit is issued. Mv s'orkers' compensation insurance carrier and policy number are: . Travebrr Property Caeualty Company of Arnrlca('arrier: _ u&3R5E121&2G2eG 1010112021I'olicv Nurnber:F-xpires: NO I certify that in the performance of lhe s,ork for rvhich this pennit is issued. I shall not employ any person in any mannâ‚¬r so as to become subiect to the workâ‚¬rs'comgrcnsation larvs of ('alifornia. and agree that if I should bccome sub.iect lo the rvorters' compensation provisions of Section .1700 of the Latxrr Code. I shall. forthwith comply with those provisions.. WARNIN(i: Failure to sec'ure u,orters'comgrensalion coverage is unlau,ful. and shall subiect an employer to criminal penalties and civil fines up to one hundred lhousand dollars ($100.000). in addition to the cost of compensation. damages as provided for the Section .1076 of the l,ahor Code. interest and attorney's fecs. LIC}'NSFN CON'TRACTOR NFCI ARA'TION I hereby affirm under penalty of periury'that I am licensed under provision of Chapter g (commencing rvith Section 7000) of Division .1 of the Business and Professions ('ode. and my license is in full force and effect. c20 l-iccnse ('lass:t22a7a l.icense Nurnber CONSTRI.ICTION I ENnlNG AGFNC}' I herebv afTinn under penalty of periun'that there is a construction lending agency for the performance of the rvork forrvhich this permit is issued (Sec. 3097. Civ. C.). knder's Name: I-ender's Address: APPLIC ^ NT DECLARATION I herebv aftinn under penalN of per luw one of the followtng declaranons I)errrolrtron Pennrts-r\shestos Notrticatron Federal Regulatrons (T'rtle 40. Pan6) !o Required l.etterof Notification t-t1 , certib' that rhe fHerat regulations regarding asbestos removal are not applicable ro this projecr. ttl , cefli8' that t have reacl this application ancl state that the above information is correct. I agree to comply'rvith all City and County ordinances and State [.au's relating to building corstntction. and herehy authoriz.e representatives of this City and Countl'to enter upon the above mentioned property for inspection purposes. Reroof Roof (Diaphragm Sheathing/Frame) Structural Final Plumbing Under Floor 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 I Rough irl:y-tu tu) 71 Electrical Final n'llr,I-t fr) 31 Mechanical t, Gas Air Pressure Test Rough Piping (HW,CW, etc.) Exhaust Ducts Mechanical Final Notes, Remarks, Etc.