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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcrcby aflirm undcr penalty of perjury that I m excmpt frcm thc CoNmctors' Liccnre Law for the following rcasn (Se.7031.5 Busincss ud Profcssion Codc): Any Ciiy or County which rcquircs a lrcmit to onstruct, altcr, improvc, dcmlish or repair any slruclurc, prior to its issumc, also rcquires thc opplicant for such prmit to lile a signcd statcrcnt that hc or shc is liccnsd pursuant lo thc provisions of thc Contractor's Liccnrcd Law (Chaptcr 9, Comrcncing with Sstion 7000 of Division 3 of thc Busincss snd PmfcssionsCodc)orthathcorshcisexcmptthcrcliomandthcbssisl'orthcallegcdexemption. AnyviolationofsectionT03l.5byBny applicant for a pcmit subjects the applicant to a civil pcnalty of not mrc thar fivc hundrcd doll&s ($500). -1. as owncr of thc propcrty. or my cmployccs with wagcs as their solc compcnsation. willdo the work and thc structure is not intendcd or off'crcd for sale (Scc.7(X4, Busincss and Professions Code: The Contractor's Liccnsc Law docs not apply to an owner of thc proprty who builds or itnproves thcrcon, and who docs such work hirnsclf or hcrsclf or through his or hcr own cmployccs. providcd that such improvcmcnls arc not intcndcd or offcred fbr salc. If. howcvcr. thc building or improvcrncnt is sold within onc year of complction, the Owncr Buildcr will have the burdcn of proving that he or she did not build or improve the proprty for thc purlnsc of salc). -1. a.s owncr of thc propcrty, am exclusivcly contracting with liccnscd contractors to construct thc projcct (Scc. 7044. Busincss ard Profi:ssion Codc: The Contractor's Liccnse Law docs not apply to an owncr of propcrty who builds or inrprovcs thcreon. and who contracts for such projccts with a Contractor(s) licenscd pursuant to thc Contractor's Liccnsc Law). _l am excmpt undcr Section_, B. & P.C. for this rcason. I\.rI o.( l.r, nar. WORKERS' COMPENSATION DECLARATION I hcreby aftirrn undcr pcnalty of perjury one of the following dcclarations: -l have ad will maintain a Certificate of Consent to Self-lnsure for workcrs' compensation, as provided for by Section 3700 of thc Labor Codc. tbr thc pcrfbrnrancc of the work for which thc pcrnrit is issucd. -l havc and will nraintain as by Section 3700 of the labor Code, for thc perfornuncc of carrier and policy number arc:thc work for which this o 3t)ilaC Policy a c3q a 4.zq-21 -l cenity that in thc pcrlbrmancc of thc work for which this permit is issucd. I shall not cmploy any person in any manncr so as to bccomc subjcct to the wofkers'cornpcnsation laws of California, and agree that if I should bccome subject to the workcrs' compensation provisions of Section 3700 of the Labor Codc, I shall. forthwith comply with those provisions. WARNING: Failure to securc workcrs' conrpensation covcrage is unlawful. and shall subject an onploycr to crinrinal Jrcnaltics and civil fines up to one hundred thousand dollars ($100,000), in Scction 3076 of thc Labor Code, intcrcst and attorney's fccs. to the cost of danmgcs Ho'id'airn' 't'" orr". - /5-/s - z/ ? I hcrcby aflirrn under pcnalty of pcrjury that I am liccnsed under provision of Chaptcr 9 (commencing with Scction 7000) of the Busincss and Profcssions Codc, and nry liccnse is in full fbrcc and cffcct. t of Division 3 Liccnsc a e 7s7e 6q Dare: t 6'(5 ' 2\I eo, CONSTRUCTION LENDING AGENCY I hcrcby uflirm undcr lEnahy ofpcrjury that thm is a @nstruction lcnding agency for thc pcrformncc of lhc work for which this pcrmit is issucd (Sec. 3@7, Civ. C.). Lcnder's Namc: I-rnder's Addrcss: APPLICANT DECLARATION I hereby affrnn under penalty of perjury onc of the following dcclarations: Dcmolition Permits-Asbestos Notification Federal Rcgulations (Title 40, Part6) -Required Letter of Notilication -l certify that the fedcral regulations rcgarding asbestos rcmoval are not applicable to this projcct. &""nify that I havc rcad this application ancl state that the above information is correct. I agrce ro comply with all City and County ordinarrccs and Statc Laws rclating to building construction. and hcrcby of this City and County to cntcr upon thc abovc nrcntioncd propcrty for inspcction eaoSoApplicant or Iternrilec e tb ,rs. z Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bf loor/Ve nt/l nsu I atio n Roof Sheathinq Shear Wall Framinq lnsulation/Enerqy Drywall Ext./lnt. Lath Brown Coat lMasonrv Pool Fence T-Bar Handicap Req. Deputy Final Report Enqineer Final Report Flood Zone Certif. FINAL e-lj-?t \r"cf elz- Certificate of Occupancy Notes, Remarks, Etc.