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BUILDING- INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bf loo r/VenUl ns u latio n'Roof Sheathing I a-(5-21 U-,W @) Shear Wall -v Framinq Insulation/Energy Drywall Ext./lnt. Lath Brown Coat [\4asonry Pool Fence T-Bar Handicap Req. Deputy Final Report Enqineer Final Report Flood Zone Certif ^/ ,/./l /-?_ F!NAL e,{d Certificate of Occupancy I NOtes, Rqmarks, FIc /\,lI,?I A Yfubo,/tuY,( OWNER BUILDER DELCARATION I hcrcby affirm under pcnalty oi prjury that I &n excnrpt frnm thc Contraclors' Liccnrc law for thc following reason (Scc.7031.5 Buslncss and Profession Codc): Any City or County which requircs a Jrrmit lo construcl, alter, improvc, dcmolish or repair any stnrcture. prior to its issuancc. also requircs thc applicant for such pcrmit to filc a signed statcmcnt that hc or shc ls liccnscd pursuanl to thc provisions of thc Contractor's Licensed law (Chapter 9, Commencing with Section 7000 of Division 3 of the Busirrcss and Profcssions Codc) or that te or shc is cxernpt thcrcfrom and thc basis for thc allcged cxemption. Any violation of Section 7031.5 by any applicant for a pcrmit subjcrcts the applicant to a civil pcnalty of not morc than five hundred dollars ($5001. _1. as owncr of the propcily, or my cmployees with wages as their sole compcnsation. will do thc work and thc structurc is not intcndcd or offcrcd f<rr salc (Sec.7044. Busincss and hofcssions Codc: Thc Contractor's Licensc [:w docs not apply to an owncr o[ the propcrty who builds or inrprt'rves thcreon and who docs such work hirnsclf or hcrself or through his or her own cmployccs. provided that such improverncnts arc not intendcd or offercd for salc. lf. howcvcr. thc building or intprovetnent is sold within onc ycar of cornplction thc Owrrcr Buikler will have the burden of proving that trc or she did not build or improve thc propny for ttrc purposc of sab). _1. as owner of the property. am cxclusivcly contractrng with liccnscd contractors lo constmct thc projcct (Scc. 7W. Busittcss and t\otbsskrn Code: '[hc Contractor's Liccnse Law docs not apply to an owner of propcrty who builds or inrproves thercon. and who conlracls for such proicts with a Contracto(s) liccnsed pursuant to the Contraclor's Liccnsc Law). -l am excmpt undcr Scrction-. B. & P.C. for this rcason. Date:_-__ WORKERS' COMPENSATTON DECLARATION I hereby affirrn under pcnalty of pcrjury one of thc following dcclaratiotts: _l havc and will maintain a Certilicate of Conscnt to Sclf-lnsurc for workcrs'compcnsation. as gnovidcd for bySection 3700 of the [:bor Code. for the pcrformance of the work for which the pernrit is issucd. _lhavcandwill rnaintainworkers'compcnsationinsurancc,as rcquircdbySection3Tfi)ofthcLaborCodc.forthepcrforrnanceof thc work for which this pcrmit is issucd. My workcrs' compensation insurancc carricr ruxl plicy numbcr arc: Policy Numbcr: Expircs: _l certify that in the pcrformancc of the work for which this prmit is issucd. I shall not employ any pcrson in any rnnncr so as to bccomc subjcct to thc workcrs'comfrcnsation laws of California. and agrcc that if I should bcconr subjcct to the workcrs' compcnsation provisions of Scction 37fi) of thc l":bor Codc. I shall. forthwith cornply with those provisions. WARNING: Failure to sccurc workcrs' compcnsation covcragc is unlawful. and shall subjcct an cmploycr to crirninal Jrcnaltics and , civil fincs up to onc hundrcd thousand dollars ($100.000).in Aition lo thc cost o[IM danrages as provided for thc Scction 3076 of thc l-abor Code, intcrcstf llo 7o arrd attorrcy's ,"r., ' I I-t, DT'CI ARATION I hcrcby affirm under pcnalty of pcrjury that I am licensctl undcr provision of Chaptcr 9 (cornnnncing with Scrtion 7000) of Division 3 of the Busincss and Professions Code. and my liccnse is in full forcc and effcct. Liccnsc Date, I I ,roeo W I hcrcby uftirm udcr Fnalry of pcrjury Ihsl tlw is a snstruction lcnding agcrcy for thc tErfor|lrmc of thc work for $,hich lhis Imh is issucd (Scc. 3097. Civ. C.). [,cndcr's Namc: frntlcr's Addrcss: APPI ICANT DECLAITATION I tueby aflirm under pcnalty of perjury one of thc following declarations: Dcmolition Pcrmits-Asbcstos Notification Fcderal Regulations (Titlc 40, Part6) -Requircd lrtter of Notification _-l ccrtify that thc fcdcralrcgulations rcgarding asbcslos renxrvalare nol applicablc to this projcct. _l certify that I havc rcad this application and statc that thc abovc information ordinanccs and Statc l,rrws rclating to building construction, and thc ahlvc nrntioned propcrty for Applicant or Agenl l'ernrilee nnnre f(r rc{(1 5 2oLc) Rev. 08-07-201 5 //;t6//{ 0wner:_ e