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SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILNER DELCARATION I hereby affirm under penalty of perjury that I am exempt form the Contractors' Liccnse Law for the following reason (Scc.70-11.5 Business and Profession Code): Any City or County which requires a pcrmit to construct. altcr. improve. demolish or repair any structure, prior to its issuance. also rcquires the applicant frlr such permit to file a signed statanent that he or she is licensed pursuant to the provisions of the ('ontractor's Licensed Law (Chapter 9. Commencing with Section 7000 of Division -i of the Business and Professions Code) or that he or she is exarpt thercfrom and the basis for the alleged excmption. Any violation of Section 7031 .5 by any applicant for a perrnit subjecs the applicant to a civil penalty of not more lhan fir'e hundred dollars (3500). !o- t, .r owner of the property. or my employees with wages as their sole compensation. will do the wort and the s[ucturâ‚¬ is nor intended or offered for sale (Sec.7044, Business and Professions Code: The Contr-actor's Liccnse law does not apply to an owner of thc fopcrty rvho builds or improves thereon. and who docs srch wort himself or herself or through his or her own cmployees, providcd that such improvements are not intended or offcred for sale. lf, howwer. the building or imp,rovanent is sold within one year of ccrmplaion. the Owner Builder rvill have the burden of proving that he or she did nd build or improve dre properw for the purpose of sale). !o t. .. owner of the property. am exclusively contracting wirh licensed contractors to construct the project (Sec. 7M4. Business and Profession Code: The Contractor's l,icense Law does not apply to an owner of property who builds or improves thereon, and rvho contracts for such proiects rvith a Contracto(s) licensed pursuant to the Contractor's Liccnse Law), Io I urn exempt under Section - - B. & P.C. for this reason. woR.KFRS' COMPFNSATTON nrcl ^ rtATtON I hereby alTinn under penalty of perlury one of the following declarations: Nlt n.". and rvill maintain a Cerrificate of Consent to Self-tmure for workers' compâ‚¬nsation. as providod for by Section 3700 of the l.abor Code. for the performance of the work for which the permit is issued. YE8 _ I have and will maintain rvorkers' compensation insurance. as required by Section 3700 of the labor Code. for the pcrformance of the work for which this perrnit is issued. My workers' compensation insurancc carrier and policy number are: can-ier: Stato comP Inr Fund 92Ea02t Policy Numtrer:_ NO Expires: 09t1112021 -_ I certify that in the performance of the work for which this permit is issued. I shall not employ any person in any manncr so as to become sub.iect to the workers' compâ‚¬nsation larvs of California. and agree that if I should become subiect to the workers' compensation provisions of Section -1700 of the l-abor Code. I shall. forthrvith comply with those provisions.. WARNIN(i: Failrne to secure n,orters' compcnsation coverage is unlarvful. and shall subiect an employer to criminal penalties and civil fines up to one hundred thousand dollars ($100.000). in addition to the cost of compensation. damages as provided for the Section 3076 of the Labor ('ode. intetest and attomey's fecs. t ICENSFN ('ONTRA(TOR NF'CI ARATION I hereby affinn under penalty of periury that I am licensed under provision of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code. and my license is in full force and effect. c-30 l.icense Class: 1070058 l.icense Nurnber CONSTRTICTION I FNNING AGFNCY I hereby afTirm under penalty of per.iury that there is a construction lending agercy for the perfornunce of the work forwhich thispermit is issued (Sec. -1097. Civ. C.). l.ender's Name: _ l.ender's Address: _ APPI I('ANT NFCI AR.ATION I hereb,v aftimr undel penalty of per.|ury one of the followrng declarations Denmlrtion Pernrrts-Asbestos Notrfrcatron Federal Regulatrons (Trtle 40, Part6) No_ Requirecl [rtter of Notifi cation YEs I cefliry that the federal regulations regarding asbesros removal are not applicable to this proJect. tI f cefliS/ thar I have read this application and state that the above information is correct. I agree to comply wirh all City and County ordinances and State l-aws relating to building construction. and hereby authorize representatives of this City and County to cxter upon the atrove mentiord property for inspection purposes. Reroof Roof (Diaphragm Sheathing/Frame)8-t(-zt Ea,"af t41 Structural Final 8-\j-2^Dzi<rt' {t Plumbing Under Floor I Under Slab Rough Shower Pan / Tub Test Water Service Sewer / Sewer Cap Gas Air Pressure Test Plumbing Final Electrica! Service (Meter I Panel) Grounding / Bonding Rough Electrical Final Mechanica! Gas Air Pressure Test Rough Piping (HW, CW, etc.) Exhaust Ducts Mechanical Final Notes, Remarks, Etc. INSPECTOR RECORD I ,