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BUILDING- INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcreby affrrm undcr pcnalty of Frjury that I m excmpt ftom thc Contrrclos' Liccns law for thc following rcamn (Sc.7031.5 Busincss rnd Prcfcssion Codc): Any City or County which rcquircs a JErmit to construct, altca improvc, dcmlish or rcpair any structurc. prk r to ils Lssu8rcc. als rcquircs the applicant fo] such lErmit to filc a sigrcd statcmnl th.t hc or sh6 is liccnsd pwsuant to thc provlsions of thc Contractor's Liccnsd lxw (Chaptcr 9, Commercing with S6tion ?000 of Division 3 of the Busircss and PrcfessionsCodc)orthathcorsheiscxcmptthcrcfmmandthchsisforthcollcgcdcxcmption. AtryviolationofscclionT0.ll.5byany applicant for a Frmit subjccts the applicant to s civil pcnalty of not mrc thil fivc hundrcd dollus (5500), _1. as owncr of thc propcrty, or my cmployecs with wagcs &s their solc compcnsation, will do thc work and thc structurc is nol intcndcd or offcrcd for salc (Sec.7044. Business and Profcssions Codc: Thc Contractor's Liccnsc Law docs not apply to an owncr of the pmpcny who huilds or improves thcrcon, arxl who docs such work hinrself or hcrsclf or lhrough his or hcr own employccs. providcd that such improvcnrcnts arc not intcndcd or offcrcd lbr sah. lf. howcvcr, thc building or improvcnrcnt is sold within onc )rcar of conrplction, thc Owner Buildcr will havc the burdcn of proving that hc or shc did not build or inrprove the propcrty for thc purlnsc of salc). _1, as owncr of thc propcrty, am cxclusivcly contracting with liccnscd contraclors to construct thc projcct (Scc. 7M4, Busincss and Proti:ssion Codc: Thc Contractor's Liccnsc Law docs not apply lo an owncr of propcrty who builds or improvcs thereon. and who contrdcts for such projccts with a Contracto(s) licenscd pursuant to thc Contractor's Liccnsc taw). -IamcxcmptunderScction-.B.&P.C.lbrthisrcason. \ Date:_Owner:_ WORKT.'RS' C()M PENSATION DECLARATION I hercby affirm undcr pcnalty of pcrjury one of thc following dcclarations: _l havc and will maintain a Ccrtificatc of Consent to Sclf-lnsure fbr workcrs' compcnsation, as providcd for by Scction 3700 of thc Labor Codc. for thc pcrformancc of thc work for which thc ;rcrmit is issucd. _l havc and will maintain workcrs' c<lnrpcnsation Scction 3700 of thc Labor Codc, for thc pcrfbrnuncc of thc work tbr which this is issucd.carrier and plicy numbcr are: Policy to /tv 1z-rlt -l ccrtify that in thc perfbrmance of thc work lbr which this pcrnrit is issucd, I shall not cmploy any pcrson in an) manner lio as to hccome subjcct to thc workcrs' comlrcnsation laws of California, and agrce that if I should bccornc subjcct to thc workcrs' compcnsation provisions of Scction 3700 of thc l,:rtnr Codc. I shall. forthwith cornply with thosc provisions. WARNING: Failurc to sccurc workcrs'compcnsation covcragc is unlawful, and shall subject an cntploycr to artd civil tincs up to one hundrcd thousand dollars (S100,0m1. in addition to lhc cost the Scction intcrcst and DECI,ARATION I hcrcby altrrm under penalty of perjury that I am liccnscd undcr provision of Chapter 9 (commcncing with Scction 7000) of Division 3 of thc Busincss and Profcssions Codc. and my liccnse is in fulllorce and ctlcct. Liccnsc Nurnbcr:o -91 qlm t 't I hcrcby {flirm undcr lEmhy of perjury that thcrc is a conslruction lcnding agcrcy for lhe fsformncc of thc work for which this lsmit is issued (Sa. 3O97. Civ. C.). Lcndcr's Name: lrnder's Address: APPI ICANT DECLARATION I hcrcby aflinn under pnalty of perjury one of the following declarations: Dcmolition Permits-Asbcstos Notification Fedcral Regulations (Tillc 40, Part6) -Rcquired l.cttcr of Notilication -l certify that thc fcdcralregulations rcgarding asbcstos rcmovalarc not applicablc to this projcct. q _l ccrtify that I havc rcad this application and statc that thc above is corrcct. I agrcc to comply with all City and County ordinanccs and Statc [:ws abovc rrrcnlioncd propcrty rcprcscntativcs of this City and County lo cntcr uJxln thc Applicant or Agent lDernrilee nanle \ Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf Ioor/Ve nt/l nsu latio n Roof Sheathinq Shear Wall Fram lnsulation/Energy (I \, Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req. Deputy Final Report Enqineer Final Report Flood Zone Certif. FINAL Qln/u l^xZ. Certificate of Occu Notes, Remarks, Etc. b Expircs: ^10