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- BUILDING. INSPECTOR RECORD SITE-WORK DATE ID/S!G.COMMENTS OWNL,R BUI T,DER D},T,CA RA'I'ION I herehy affirm under penalty of perjury that I am exempt from the Contractors' l-icense Law frrr the following reason (Sec.70.ll,5 Business and Profession Code): Any Clity or County which requires a Jrermit to construct. alter, improve. tlenrolish or repair any r structure. prior to its issuance. also requires the applicant for such Jrrmit to file a signed statetrEnt that he or she is licensed pursuant Io the pnrvisions of the Contractor's Licensed Law (Chapter 9. Commencing with ,section 7(XX) of Division 3 of the Business and Pnrfessions Code) or that he or she is exempt therefrom anrl the basis for the alleged exemption. Any violation of Section 7031 .5 by any applicant firr a permil subjects the applicant to a civil penalty of not nrrre than five hundred dollars ($5tXl1. -1. as owner of the property. or my empkryees with wages as their sole comJrensntion. will do the work and the struclurc is not intentletl or offered for sale (Sec.7044. Business and hofessions Code: The Contractor's License Law does not apply to an owner of the pnrJrerty whr huilds or impnrves ttrreon. anrJ whr drrcs such wrrrk himself or herself or through his or her own empkryees, provitletl that such impnrvenrnts are not intended oroffered frlr sale. If, hrwever. the huikling or inpnrvenrnt is snkl within one yâ‚¬:r of completion, the Owner Buikler will have the burden of proving that he or she dkl not huikl or improve the property for the puryrse of sale). -1, asownerof the property, amexclusivelycontracting with licensetl contracto$to c()nstruct the project (.Sec.7044. Business antl Pnrfessirn Cotle: The Contractor's License Law tkres not apply to an owner of property who builds or improves thereon. and who contracts for such projects with a Contracto(s) licensed pursuant to the Contractor's Lic'ense Law). -l am exempt untler Section_. B. & P.C. for this reason. l)ale: - Owner:_ WORKIIRS' COMPENSATION DECLARA']'ION I hereby affirm under penalty of perjury one of the firllowing declarations: -l have and will maintain a Certifrcate of Consent to .Self-lnsure for workers' compensation. as pnrvided for hy .Section 37(X) of the Latnr Code. for the perfrlrmance of the work for which the permit is issued. -lhaveandwill maintainwrtrkers'comJrcnsationinsurance.as requiretlhy.Section.lT(X)ofthel-ahorCotle.fortheJrcrformanceof the work firr which this permit is issued. My workers' compensntion insurance carrier and plicy number are: Policy -l certify that in the ;rerformance of the work f<rr which this prmit is issued, I shall not emphy any frcrson in any manner so asto hecrlrne suhject to the wrlrkers'comfrcnsation laws of Califrlrnia. and agree that if I shlukl become suhject tothe wrtrkers' crtmpensation provisions of Section l7(X) of the l;rhrr Crile. I shrll. forthwith cornply with provisions. WARNIN(i: Failure to secure workers' compensation c()verage is unlawful. and subject an to criminal penalties and civil fines up to one hundred thousantt dollars ($l(X).(XX)), in atldition to the comfrcnsat as provided frrr the Section .1O76 of the l.atxrr Code. interest antl attorney's fees. Drn, L) '? s -2 L' )lAppricant: I herehy affirm untler penalty of perjury that I am licensed un<ler provision of Chapter 9 (comrrncing with Section 7fiX)) of Division 3 of the Business and hofessions Code. and my license is in full firrce antl effect. License Date:_4* \s-z ot7 l- CONS'T'RUC'TION LENIIING AGENCY I hereby affirm under Jrenalty of per.iury that there is a construction hntling agency for the Jrerformance of the work for which this permit is issued (Sec. 3097. Civ. C.). Lrnder's Name: Lender's Address: APpLICAN'I' DECLAR {'l'tON I hereby affirm under penalty of perjury one of the folkrwing declarations: Demolition Permits-Astestos Notification Federal Regulations (Title 40, Part6) -Required Letter of Notifrcation -l certify that the federalregulations regarding asbestos rerxrvalare not applicahle to this pro.iect. -l certify that I have read this application antl state that the atxrve ts with all City and County ordinances antl .State Laws relating to building construction. and hereby and County to en(er up()n the ahrve mentioned property for inspection Applicanl or Agent Signature: l'erntilee nlnre w a orrr, -l 'L9-2 oll Set Backs Forms/Steel/Holdowns lo-ll-ri LOHta I Erection Pads UFER Ground SLAB Floor S u bf loor/Ve nUI ns u I ation Roof Sheathing Shear Wall fqming lnsu Iation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry /o -ll? I o n*,d ^/at halcatâ‚¬ Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif F!NAL 7>Z.ZoU tL (-os ilsrlts -UI Certificate of Occu pancy Notes Remarks , Etc. [:lev. 0B-0 f-201 5 Dfr