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BUILDING. INSPECTOR RECORD SITE-WORK DATE !D/S!G.COMMENTS OWNER BUILDER DELCARATION I hccby afiirm undo penalty of pcfjury that I m cxcmpt from thc ContBctoE' Licsc Lrw for the following @n (Se.7031.5 Buitrs ard Prcfsion Code): Any City or County which rcquirs a pqmit to coNtruct, altc, improvg danolish or rcpair my structuc, prior to its isuocc. also rcquirc thc applicet for such Fmit to filc a signcd statmat that hc or slE b licqEcd pllls@t to thc provisioN of thc Conrrctor's Licascd taw (Chapt6 9, Comencing with Setion 7000 of Division 3 of thc Buins ud ProfwionsCode)orthathcorshciscxmptthqe+omudthcbasisfortheallcgedcxmption. AnyviolatiotrofSetionT03l.5byuy applicant for a pqmit subj6{s thc applicilt to a civil pffilty of not morc thil five hun&cd dolles ($500). -1. as owner ofthe property. or my employees with wagcs as their sole compensation. willdo the work and the structure is not intendod or offered for sale (Sec.7M4, Business and hofessions Code: The Contractor's License Law does not apply to an owner of the property who bnrilds or improves thermn. and who does such work himself or herself or through his or her own cmployees, providcd that such improvanents are not intended or ofFcrod for sale. I[, however. the building or improvernent is sold within one ]aar of complaion, the Orvner Builder will have the burden of proving that he or she did not build or irnprove the p,ropoty for the purpose of sale). _1. as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Btsiness and Proftssion Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon. and who contracts for such projects with a Contractor(s) licersed pursuant to the Contractor's Licerse taw). -l am exempt under Section-. B. & P.C. for this reason. Owner: WORKERS' COMPENSAT DECLARATION I heyeby aflirm under penalty of pojury onc of the following declarations:J_l have and will maintain a Certificate of Consent to Sclf-lnsure for worketrs' compq$ation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which the perrnit is issued. -l have and will maintain workcrs' compensation irsurance, as required by Section 3700 of thc l-abor Code, for thc pcrformance of the work for which this pernrit is issued. My workers' compcnsation insurance carrier and policy numbcr arc: Carrier: t - Policy Nurnbcr: Expires: _l certi& that in the perfonnance of the work for which this pennit is issued. I shall not employ in any manner so as to bccome subject to the workers'compensation laws of California, and that if I subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall.with those provisions. WARNING: Irailure to secure rvorkers'is an anployer to criminal penalties and civil fincs up to one hundred thousand of cornpensation, damages as provided for thc Section 3076 of the tabor interest and attorney's fees. I hereby affrm under penalty of perjury that I arn 9 (corrunencing with Section 7000) of Division 3 of the Busincss and Professions Code. and my license is in full force and effect. . CL\'a License l)q I r.'-1--tl I hereby a{Iirm under pcnalty of perjury that there issued (Sec. 3097, Civ. C.). Lendcr's Namc: agency perfonnance of the work for which this pcrmit is Lcnder's Address: APPLICANT DECLARATION I herdry affrrn under penalty of perjury one of thc following declarations: Demolition Perrnits-Asbestos Notification Fcderal Regulations (Title 40, Par16) _Required Letter of Notification I cerrifo that the E;,r,n", Ihave federal regulations are not applicable to this project. read this above information is correct. I agroe to comply with all City and County ordinances and State [arvs relating to and hereby authorize represertatives of this City and County to entcf upon the above mentioned property for Applicant or Agent Pernritce nRme Cu e ,",. -l-1-.\-2/ Set Backs Forms/Stee!/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloor/VenUl nsu latio n Roof Sheathing Shear Wall Framing lnsu lation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif Px/d;r lr*t C- a.?-\ :tutl? Am D/,!rl6 bq Paorraa 3-tl- ?-r A*{lz FINAL Q,1q-r/s M 9r- Certificate of Occupancy Notes, Remarks, Etc. -)> a