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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hoeby affm undc pcnalty of pcrjury thsl I m cxempt frpm thc Contmcto6' LiccN law for thc following tlen (Ss.7031.5 Buins and Profsion Code): Ary City or Comty which requirG a pqrnit to contrucl, altc. improvc, dauolish or rtpair my structuc, prior to its isumcc, also rcquira thc applimt for such pennit to file a signcd statm@t rha he or sltc b licmcd pmwt to the provisiore of thc Contrrctor's Liccnscd taw (Chaptq 9. Comcncing with Sction 7000 of Division 3 of thc Buins md Prcfeions Codc) or that hc or she is cxmpt thscfrom ed thc basis for thc alle3ed cxmption. Any violatioo of Satbn 7031.5 by ily applicmt for a pcrmit subjcts the applicant to a civil poalty ofnot morc thm fivc hundrcd dollus ($500). _1. as owner ofthe property, or my cmployees with wages as their sole compouation. will do the work and the structure is not intended or offered for sale (Sec.7044. Business and Professions Code: The Contraclor's Licensc law does not apply to an owner of the property who builds or improves theron" and who does such u,ork himself or hersclf or through his or hcr own employees, provided that such improvanents are not intended or oflâ‚¬red for sale. I(, howcrver. the building or improvement is sold within one year of complaion, the Or,vner Builder will have the btudcn of proving that he or she did not build or improve the propo'ty for the purpose of sale). -_1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7M4, Business and Profâ‚¬ssion Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon. and who contracts for such projecls with a Contracto(s) licensed pursuant to the Contraclor's License taw). -l am exempt under Section-, B. & P.C. for this reason. I)o to' \ryORI(ERS' COD1PEN SATIO N DECLARATION I hereby affirm under panalty of perjury one of the following declarations: _l have and will maintain a Certificate of Consent to Self-lnsure for workers' compensation, as provided for by Section 3700 of the l-abor Code, for the performance of thc work for which the perrnit is issued. _l have and will maintain workers' compensation insurance. as required by Section 3700 of the Labor Code, for the performancc of the work for which this pcnnit is issuod. My workers' compensalion insurancc carier and policy numbcr are: Policy _l certi& that in the perforrnance of the for which this permit is issued. I shall not onploy any person in any manner should bc.come subject to.lh"so as to become subject to the workers'compensation laws of California, and agree that if I workers' compensation provisiorrs of Section 3700 of the Labor Code. I shall. forthrvith cornply wilh thosc provisions. WARNING: Failure to secure workers' compensation coveragc is unlawful. and shall subject an ernployer to criminal panalties and civil fines up to one hundred thousand dollars ($in addition to the cost of compensation, damages as provided for the Section 3076 of the labor Code, intercst and attorney's DE('I,ARAI'ION I hereby affrrm under penalry of perjury that I am licensed under p,rovision of Chapta 9 (commancing with Section 7000) of Division 3 of the Business and Professions Codc, and my license is in full force and effect. License ul r ] -7 35 CONSTRUCTION LENDING AGENCY I hcby afiim undo pcf,alty of psjury that th@ is a @nstruction landing agocy for thc pqfomcc of thc wrk for which this pqmit b issued (Se. 3097. Civ. C.). Lender's Name: Lcndcr's Address: APPLICANT DECLARATION I herdryaflinn under penalty of perjury one of the following declarations: Demolition Permits-Asbestos Notification Federal Regulations (Title 40, Pafl6) _Required lrtter of Notification _l certi& that the federalregulations regarding asbestos removalare not applicable to this project. -l certiff that I have read this application with all City and County and County to emtâ‚¬r upon theordinances and State laws relating to above mentioned property for Applicant or Agent Pcrnritee name (nrint): .-U -Zt Set Backs /,It --- Forms/Steel/Holdowns Erection Pads I UFER Ground SLAB Floor S u bfloor/Ve nU I n s u latio n Roof Sheathing Shear Wall Framing lnsulation/Energy Dnnryall Ext./lnt. Lath Brown Coat Masonry /,f/rr Pool Fence I ?/t7hl T-Bar y -r Handicap Req. Deputy Final Report Enqineer Final Report Flood Zone Certif. ^l J It t , F!NAL 'llH11 I uriltru U,W Certificate of Occupancy Notes, Remarks, Etc. Exoires: orr"r-5 -z-l -?l 7/r/v/u{&a v&ltr , ?fr