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BUILDING. INSPECTOR RECORD SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATTON I hccby affrm unde pcnalty of pcrjury that t m cxcmpt 6om thc ConracloB' LiccN lrw for thc following lten (Se.7031.5 BGins md Profsion Code): Any City or County which rcquirs a p6nit to coNtruclr altq, improvq danolish or rcpair my strucluc. prior to its issumcc, aho rcquire thc applicilr for such pamit to filc a sigtrcd ststmot tha hc or shc b licoscd pmmt to the Eovisions ofthe Contrrctor's Liccnsed taw (Chaptq 9, Commcncing with Setion 7000 of Division 3 ofrhe Busins md r Prcfcssions Codc) or that hc or shc is cxmpt thqcfrom ed the basis for the allcgcd cxopion. Any violation of Setion 703 I .5 by my ffi ;-;#ffiffiffi;;;*ffi*,**********", thc prcIsty who buil& or improvc thqor\ ild who doe srch mrk himself or helf or tluough his or ha om mployes. provided rhat such imlrcvffits rc not itrtqrdcd or offqql for slc. lf, howds, thc building or irwovcrmt is $ld withir onc )@ ofomplaion, the Owno Buiklr will harc thc hrdqr ofproving tlra hc or shc did mt build or improrc thc propoty 6r thc pupor of sle). _-1. as owner of the property, am exclusively contracting with licensed contractors to construct the project (Scc. 7044. Busincss and hoftssbn Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a Contracto(s) licensed pursuant to thc Contractor's License l-aw). _l am B. & P.C. {LI DECLARATION I hereby affinn under penalty of perjury one of the following declarations: -l have and will maintain a Cerlificate of Consent to Self-lnsure for workers' compensation. as provided for by Scction 3700 of the labor Code, for the performancc of thc work for which the permit 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 permit is issued. My workers' compensation insurance carrier and policy numbcr are: A Policv Nurnbcr' br...riryrno, _Expires: in the performancc of the rvork for which this pcrmit is issued. I shall not employ any pcrson in any manner so as to becorne subject to the workers' compensation laws of California, and agree that if I should become subject to the rvorkers' compensation provisions of Section 3700 of the Labor Code, I shall. forthrvith comply with those provisions. WARNING: Failurc to scrure workers' compensation coverage is unlawful, and shall subject an employer to criminal pcnalties and civil fines up to one thousand dollars ($100,000), in addition to the of compensation.for the Section 3076 of the interest and attorney's fees. (t DECLARATION I hereby affrm under penalty of perjury that I arn licensed under provision of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Codc, and my license is in full force and effect. License Class: License Number: CONSTRUCTION LENDING AGENCY there is a construction lending agency for the performance of the work for which this perrnit is Lcnder's Addrcss: APPLICANT DECLARATION I hereby affrrn under penalty of perjury one of the following declarations: Demolition Permits-Asbestos Notilication Federal Regulations (Title 40, Part6) -Required lrtter of Notification I certifo that the E*irytr,u, I have fbderal regulations regarding asbcstos removalare not applicable to this projcct. read this application and state that the above infonnation with all City and ordinances and State Laws relating to upon the above mentioned propcrry for \tppticant or Agent Permitet' nanlc (print): and to ZI Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloor/Ve nUI n s u latio n Roof Sheathins Shear Wall Framincl lnsulation/Energy Dnnryall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif. II FINAL Clzthr {4C JK Certificate of Occu pancy I Notes, Remarks, Etc.,A\ cd 1-/P',-e { A Carrier:_ ! f!^-. -^ ^a ^-, issued 3097. Civ. C.). Name: t a I