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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DEI.,CARATION I hseby affm undq p@alty of perjury thar I m qcmpt fipm thc Contracton' Licme Law for thc following rcun (36.7031.5 Businas and Prof6sion Code): Atry City or County which requirG a panit to coNtruct, altq, improve, dmolish or rcpeir my structuc, prior to its isumcc. also requirs thc applicut for such pqmit to file a signcd stalmot thar hc or she b licascd pEWt to the provisioN of thc Contr&tor's Licmscd Law (Chaptc 9, Comcncing with Setion 7000 of Division 3 of thc Buinas md Prcfsiotrs Codc) or that hc or shc is qmpt thefrom ad thc basis for thc allegcd cxmpion. Any violation of Sâ‚¬tbn 7031.5 by uy applicant for a ponit subjets thc applicut to a civil pcraltyofnot morc th4 6vc hundrcd dollus ($500). _1. as owner of the property. or my employccs with wages as their sole compensation. will do thc work ard thc structure is not intended or offered for sale (Sec.7M4, Business and hofessions Code: The Contractor's License Law does not apply to an owner of the property who builds or improves thereoru and who does such work himself or herself or through his or her own cmployees, provided that such improvcments are not intâ‚¬nded or offerod for sale. If, howevcr, the building or improvcment is sold within one ],car of complaiorL the Orvner Buildcr will have the hrden of proving tha hc or she did not build or imp,rove the property for the purpose of sale). _1, ils owner ofthe property, am cxclusively contracting with licersed contractors to construcl thc p,roject (Sec. 70tt4. Buiness and hrofession Code : The Contractor's License Law does not apply to an owner of property who builds or improves thereon. and who contracts for such projccts with a Contracto(s) licersed pumuant to the Contractor's Liccnse kw). -l am exempt under B. & P.C. for this reason. Date: WORKER.S' COMPENSATION DECLARATION I hereby affrrm under penalty of perjury one of the following declarations: _l have and will maintain a Cerrificate of Consent to Self-lnsure for workcrs' compensation, as provided for by Section 3700 of the labor Code, for the pcrformance of the work for which the perrnit is issued. f! hare and will maintain workers' compensation insurance. as rcquired by Section 3700 of the l-abor Codc, for thc perfonnancc of the work for which this pcrmit is issued. My workers' cornpensation insurance carrier and policy number are: poricy N,^*,,W L <1 17 4f )7 -c> c Expires:*l-t l-- _l certi$ that in the performance of thc work for which this permit is issued, I shall not employ any pâ‚¬rson in any manner so as to become subject to the workers' compensation laws of California. and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the l-abor Code. I shall. forthwith comply with those provisions. WARNING: Failure to sccurc workers' compq$ation coverage is unlawful. and shall subject an onploycr to criminal ponlties and civil I'rnes up to one hundred thousand dollars (5100,000), in addition to the cost of compensation, damagcs as provided for the Section 3076 of the Labor Code. interest and attorney's fecs. .'L I hereby affrrm under penalty of perjury that I am licensod under pnovision of Chapto 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Number:lo?-tr 3bb ",r", f / t?lzl conrractor:Y T lu l+vil l{J\-W I hseby affm unds penalty of pojury thst thqc is a erotruction lcnding agocy for thc pqfomcc of thc wrk for which this ponh b issucd (Sc. 3097, Civ. C.). Lender's Narne: knder's Address: APPLICANT DECLARATION I her*,, affirm under pcnalty of pcrjury one of the following declarations: Demolition Permits-Asbestos Notification Federal Regulations (Title 40. Part6) -Required Lctter of Notification _l certi& that the federal regulations regarding asbestos removal are not applicable to this project. _l ccrti& that I havc read this application and state that the above information is correct. I agrce to comply with all City and County ordinances and State laws relating to building construction and representatives of this City and County to enter upon above mentioned property for inspection , Applicant or Agent Permilec nanre )<_ the Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/Ve nul n s u latio n Roof Sheathing Shear Wall Framinq Insulation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputv Final Report Enqineer Final Report Flood Zone Certif FINAL 7h L,JrtVr-. Certificate of Notes, Remarks, Etc. .,,,*, 4fvrrr I Cra ?rri Clr.- a