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BUILDING. INSPECTOR RECORD (a SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION i hcrcby allirm undcr [rcnalty of JErjury lhat I am cxcmpt ltom thc Contrackrro' Liccnsc Law to] lhc folk wing rcavrn (Scc.7031.5 Busincss ard Protbssiu Culc): Any Cfuy or County which rcquircs a lErmit to consrruct, altcr. improvc. dcmolish or rcpau uny structurc, prior l(t rts issuance, also rcquircs thc applicatrt tirr such prmit Io filc a sigrcd statemnt thal hc or shc is liccns.l pusuant t) lhc provisions of thc Conlractor's Liccnscd llw (Chdptcr 9, Commcncing with Scclion 7000 of Division -l of thc BusitEss snd ProfcssnnF Codc) or lhat trc r)r shc is cxcmpt thcrcli()m and thc basis for thc allcgcd cxcmption. Any violati(rtr of Scction 7OJ 1.5 hy any applicant fi)r a lrcrmit subJsts thc applicant to a civil pcnalty of not mrre than fivc hundrcd dolles (5500). -1. as owner ()f'thc propcrty, or my employees with wagcs as thcir solc compcnsatlon, will do lhc work arxl rhc slructure is not tttlcntlc.d or ofl'crcd lilr salc (Sct'.7044, Busincss and hot'cssions C<xlc: Thc Contract()r's l-icensc Law docs not apply to an owncr 6f thc proJrcrty whrt builds or intpnrvcs thcrcrrn. aryJ who docs such work himsclf or hcrsclf or thnrugh his or hcr own cmployccs, pnrvitlcd that such impnrvemcnts arc not irrcnrlcd or oftbrcd firr 5r1". Il, howcver, the huilding or improvcmcnt is sold within ()nc yc.u ol'conplction, tltc Owner Buildcr will havc thc burden ol'pnrving that hc or she did not huikl or improve thc pnrpcrry lbr thc puryxrsc of salc). -1, as owner t>f thc propcrty. am exclusivcly contracting with licenscd conlracton to construct the projcct (Scc. 7OM. Busincss and Pnllbssirn Codc: Thc Contractor's Liccnse Law docs not apply to an owncr of proJrcrty who builds or improves thcrcon. and who conlracts lilr such pnljccts with a Contractor(s) liccnscd pursuant to the Contractor's Liccnsc Law). _l am excmpt undcr Scction_, B. & P.C. tbr this rcason. fl.r I o. WORKERS' CONT PENSATION DECLARATION I hcrcby all'irm undcr Jrcnalty ol';rcrjury onc of thc tirlklwing rlcclaratiolrs: __l havc atrl wrll maintain a Ccrtilicatc of Conscnt to Scll-lnsurc lirr wrlrkcrs' comlrcnsatlon, as providcd lirr by Section .3700 of thc l-atxrr Ctxlc, lirr lhc Jrerfilrmancc of thc work tirr which thc ;rcrmit is issucd. -l havc and will maintain workcrs' compcnsation insurancc, as rcquircd hy Scction 37U) of thc l,abor Codc, lilr the Jrcrtirrmancc of thc wlrk lor which this 1-*rmit is issued. My workers' compensation insurance carricr and Jxllicy numbcr are: Policy Number: Expircs: -l ccrtily that in thc Jrcrlirrmancc ol'thc work lilr whrch this pcrmit is issuctl, I shall not cmploy any lrcrson in any manncr so as to bccomc suhjcct to thc workcrs' comJrcnsation laws of Calitilrnia, anrl attrcc that if l stxluld t--comc subjcct to thc workcrs' com;rcnsalion provisions of Scction 3700 of thc [.ahlr Crxlc, I shall. tirrthwith conrply with those provisions. WARNING: Failurc lo sccurc workcrs'comJrcnsation coveragc is unlawtiri. antl shall suh.jcct an cmpklycr to criminal Jrcnaltrcs and civil lilrcs up to onc hundrcd thousanrl dollaus (S100,Uru). in addition to thc cost of compcnsation. damagcs as providcd tilr thc Scctiorr 3076 ol'thc Latxrr Crxlc, intcrcst and attorney's fbcs. A --l!---r^ LICENSED CONTITACTOR DECLARATTON I hcreby atlirm undcr Jrcnalty ot'Jrcrjury that I am liccnscd undcr provision of Chapter 9 (comrncncing with Section 7U)()) of Division J of thc Business and Pnll'cssions Codc. and my licensc is in lull lirrcc and cl't'cct. Liccnsc Class: Liccnsc Numbcr: rl..a^. CONSTRUCTION LENDING AGENCY I hcrcby alfrm undcr fEnalty of lrcrrury lhat thcr is a conslruction bnding agcncy for thc lErformer of thc work for which this JEmir is issucd (Sec. 3g)7, Civ. C.). kDdcr's Namc: [.cnder's Addrcss: APPLICANT DECLARATION I hcrcby aflirm undcr pcnalty ol'Jrcrjury onc ol'thc folkrwing rlcclarations: Dcmolition I'crmits-Ashcstos Notil'ication Fcdcral Regulations (Titlc 40, Part6) _Rcqu ircd lrt ter of Nolilicatkrn --l ccrtily that the t'cdcral rcgulations rcgarding asbcstos rcmovalarc not applicahlc to this projcct. -.l certily lhat I lravc rcad this application and statc that thc ahrvc with all City arrd County alrd County to cntcr uJxrn lhcordinanccs and Statc Laws rclating to building construction, ahrvc- lr^-lrtioncd pro;rrty lirr Applicant or Agent Pt nttitee nAnre *rr,.3r[,''lruZ/ Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bf loor/Ve nVl ns u latio n Roof Sheathing I l,,a Shear Wall 4t1 H ADaHr -rtU Framing rt !nsu lation/Enerqy Drywall Ext./lnt. Lath Brown Coat [Vlasonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif. FINAL (44)-?/l I BRq Certificate of Occupancy I v Notes,Etc. Elov nQ-n7-2n 1 q a