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BUILDING- INSPECTOR RECORD SITE-WORK DATE ID/S!G.COMMENTS OWNER BI.IILDER DELCARATION I hcreby affirm under penalty of prjury that I am excmpt frorn lhe Conlractors' License l^aw for the following reason (Scc.7031.5 Busincss arxl Prolbssion Codc): Any City or Counly which rcquires a permit to construct. alter. improve, dcmolish or rcgnir any struclurc. prior to its issuancc. also requircs thc applicant for such pcrmit to filc a signcd statemcnt that hc or shc is licenscd pursuant to thc provisions of thc Contractor's Licensed Law (Chapter 9. Commcncing with Section 7000 of Division 3 of the Busincss and Profcssions Code) or that he or she is excmpt thcrcfrom and thc basis for thc allegcd cxcmption. Any violation of Scction 703 t .5 by any applicant fbr a perrnit subjccts thc applicant to a civil pcnalty of not morc than five hundred dollars ($5001. -1. as owrrcr of the propcrty, or nry crttployccs with wages as thcir solc compcnsalion. willdo thc work and thc structtnc is rxll intendcd or offcrcd for salc (Scc.7044, Busincss and Profcssions Codc: Thc Contractor's Liccnsc [aw docs not apply to an owncr of thc proprty who builds or improves thcrcnn. and who docs such work hirnsclf or hcrself or through his or her own employecs. providcd that such improvemcnts arc nol intcndcd or offerccl for salc. If. howcver. thc buikling or irrqrrovcmcnt is sold within onc ycar of cornplctioru lhc Owncr Builder will have thc hurdcn of proving that hc or she did not build or improvc Orc propcrty for thc purynsc of salc). a -1. as owncr of thc proprty. am exclusivcly contracting with licenscd contractors to construct the projc.ct (Sec. 7W, Business and Rnfession Codc: Thc Contractor's License Law docs not apply to an owner of property who builds or improvcs thercon. and who conlracts for such projccts with a C-ontractor(s) licensed pursuant to thc Contractor's Licensc Law). -IamcxemptundcrSection-.B.&P.C.forthlsrcason. WORKERS' COMPB{SATION DF'CLARATION I hcrcby atlirnr under penalty of per.;ury one of thc following declarations: -lhaveandwill maintainaCerriticatcofConscnttoSclf-lnsurcforworkcrs'com[rcnsalion,as grovidcdforbyScction3T00ofthe Labor Grde, for the performancc of the work for which the prmit is issued. f, nor" and will maintain workcrs' compensati<ln insurancc, as requircd by Scction 3700 of thc [,abor Code, for the performance of thc work frrr which lrcrrnit is issucd. My workers' compcnsation insurancc carricr policy nunrbcr arc: Policy -l ccrtity that in the pcrfornrance of thc work for which this pcrrnit is issucd. I shall not cnqrloy any pcrson in any manner so as lo bcconrc subict to tlrc workers' compcnsation laws of California, and agrec lhat if I should becornc subjcct to the workers' compcnsation provisions of Section 3700 of the t-abor Codc. I shall. forthwith cornply with thosc provisions. WARNING' Failurc to sccurc workcrs'compcnsalion covcragc is unlawful, and subjcct an cmploycr lo criminal pcnaltics and compcnsation. danuges as provided for thc tcivil fincs up to onc hundrcd thousand dollars ($100.m0), rn addition to thc .Scction 3076 of the l,atnr C'odc, intcrcst and attorncy's fecs. Date:_.->-/6-3 r Applicant: _ I)I.]CI.AIIAI'ION I hereby affirm undcr pcnalty of pcrjury that I am liccnscd under provision of Chaptcr 9 (comnrncing with Scrction 7000) of Division 3 of thc Busincss and hofcssions Code, and my license is in full forcc and effcrt. License C Numbcr: Date:-.Conlractor: W I hcrcby alfrm undcr pmlty of Frjury lhsl thcrc is a @nsruction bnding rgcrcy for tlE perforlwe of thc rcrk for which this pcrmit is issed (Sec. 3097, Civ. C.). bndcr's Norrc: lrndcr's Addrcss: APPLICANT DECI ARATION I hrrcby affrm under pcnalty of perjury one of lhe following dcclarations: Dcmolition Pcrmits-Asbestos Notification Fedcral Regulations (Title 40. Prrt6) -Requircd lrttcr of Notfficathn { t cenifythat thc fcdcral regutations rcgarding asbcstos rcrmvatare not applicablc to this project. with all City and County L and County to cnter upon the above mentioned property for inspcction Applicnnt or Agent Permilee nanre statc that I )al e:?-16-fl/ Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenUl ns u latio n Roof Sheathing 0- | t-?t DGinef tl z.{lolzc.- trfr ort C.rnr Shear Wall ,?rAp1, Framing v lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat [\Iasonry Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif FINAL t_g-a #42 Certificate of Occupancy Notes, Remarks, Etc. Rev. 08-07-201 5 Dale:_ A