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BUILDING. INSPECTOR RECORD iD SITE-WORK DATE ID/SIG.- corilannENTS OWNER BUILDER DELCARATTON I hcrcby allirm undcr pnalty of prjury that I am cxempt from thc Conlraclos' Liccmc Law for thc folktlvirg rcuurn (Scc.7)31.5 Busincss srx.l Profcssion Crxlc): Any City o. County vhich rcquircs r [Ermit lo construcl. altcr, improvc. dcmolish or rpair any slruclurc, [rirr o its issume, also rcquircs lhc applicanl for such Ircmil kr fib i sigrcd statcmnl lhal hc or slrc Ls licen$d pmuant to thc provisions of thc Contract(['s Liccnrcd l:w (Chaptcr 9, Commcncing sith Settrn 7000 of Division .] of lhc Busircss and Prufcssions C(xlc) u that hc or shc is cxcmpt thcrcfrum strd thc basis tor thc allcgcd cxcmption. Any violalion of SNtion 703 1.5 by any applicant for a Frmit suhjets the {pplicant to a civil pcnally of not morc tha[ fivc hundrcd dolles ($5fi)). _1, as owncr of thc propcrty, or my cmployccs with wagcs as thcir solc comlrcnsation, will do the work and thc slructurc is not intcndcd or oll'crcd tirr sale (Sec.7044, Busirrcss and Prof'cssions Crxle: Thc Conlractor's Liccnse l,aw docs not apply to an owncr of thc propcrty wlxr builds or improvcs thcrcon, alxl wlxr docs such work himsclf or hcrsclf or through his or hcr own cmpkryecs, providcd that such improvcrncnts arc not intcmlcd or olfcrcd ftrr salc. ll, howcvcr. tlrc buikling or improvcnrcnt is sokl within onc year ol'complctnln, thc Owner BuilJcr will havc thc burdcn of proving that hc or shc did not builJ or improvc thc pmpcrty for thc purprsc ol' salc). _1. asowncrof thc property, amexclusivclycontracting with liccnscd contractom lo construct the pntjccl (Sec. 7044, Busincss arxl Pnrtbsskrn Codc: Thc Contraclor's Liccltsc Law docs not apply to an owncr of propcrty who builds or improves thcrcon, and who contracts krr such projccts with a Contractor(s) liccnscd pursuant to thc Conlractor's Liccnsc Law). _l am cxcmpt undcr B. & P.C. lirr this rcils()n. t>rt",/z- I -I -71 s, l?o ,.,<^ 1+ I hcrcby all'irrn undcr pcnalty of pcrjury onc of thc ftllklwing dcclarations: _l have arxl will maintain a Ccrtilicalc ot'Conscnt lo Sclt-lnsurc tilr workcrs'compcnsation. as providcd filr hy Scclion -1700 of thc l-ahlr Crxlc-. lirr thc Jrcrlbrmancc o[ thc wrlrk filr which thc Jrcrmit is issucd. _l havc anrl will maintain workcrs' comJrcnsation insurance, as rcquirctl by Scct ion .1700 of thc Labor Cotlc. lirr thc Jrcrlilrmancc of thc work lirr which this permit is issucd. My workcrs' compcnsation insurancc carricr arxl Jxllicy numbcr arc: Policy Numbcr: Expircs: _l ccrlily that in thc Jrcrtbrmancc o[thc work filr which this Jrcrmit is issucrl. I shall not employ any pcrson in any manncr s() as to bccomc suhjcct to the workcrs'compcnsation laws of Calilirrnia, and agrcc that if I should becomc subjcct to thc workcrs' comJrcnsation provisions of Scction 37ffi of thc l-^abor Culc, I shall. tilrthwith comply with thosc pnrvisions. r WARNING: Failurc to sccurc workcrs'conrJrcnsation covcrage is unlawtul. and shall subict an employcr to triminal pcnaltics and civil lincs up to onc hundrcd thousand dollars ($100,UX)), in adtlition to thc cost of compcnsation, damagcs as prcvj{cd firr thc Scction 1076 ot'thc Latxrr Cule, inlercst anrl l1 - 7-t \s, 1<^Z^-, <>O DECLARATTON I hcrcby alfirm undcr ;rcnalty of pcr.iury that I am liccnrcd undcr provision of Chaptcr 9 (commcncing with Scction 7U)()) of Division 3 of' thc Busincss and Professions Codc, arxl my liccnse is in full tbrcc and ell'cct. Licensc Class: Liccnsc Numbcr: Date: W I hcrcby allirm undcr Jrenalty of Frjury that thcrc is a construction bnding agcncy lirr the Frtbmnce of thc wo* lbr which this Frmit is issucd (Ss. -1(P7, Civ. C.). kndcr's Nam: l.crtdcr's Atldrcss: APPLICANT DECLARATION I lrcrcby allirm undcr Jrcnalty of pcrjury onc of thc lirlkrwing dcclarations: Dcmolition Pcrmits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40, Part6) _Rcquircd lrttcr of Notilicatiorr _l ccrtily that thc l'cdcral regulatiorts rcgarding ashcstos rcmoval arc not applicahlc to this projcct. _l ccrtity that I havc rcad this application and slatc that thc ahrvc intirrmatiorr is corrcct. I agrcc to comply with all City and County ordinanccs arrd Statc [-aws relating to construction, arxl hcreby autlxrriz.c rcprcscntatives of this City anrl County to entcr uJxln the atxlvc nrcntioncd pro;rcrty tilr purF)scs. Applicant or Agent r'e ?_- lJ- Penrritce nanrc 4 c,h= >a4< C.-. Set Backs t,n Forms/Steel/Holdowns t.J ID N \il Erection Pads r I rt /"l ,a UFER Ground l0 fi UN SLAB Floor dl hn S u bf loor/VenUl nsu latio n Roof Sheathinq -7^l - )t At Cb Shear Wall ./Lt Framinq lnsulation/Energy Drywall )+,l[hl, Ext./lnt. Lath 5-17-zl Brown Coat 7uz) @ .f4_nt.tC$r â‚¬a NlHx[ Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif FINAL -6-A \{t5L Certificate of Occupancy \-/ Notes, Remarks, Etc. Rr:rr 2n1 q ) o -('q(-, (l-Frrr,, ttt/, s (- t'/ ll7 /.^