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BUILDING. !NSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DET.CARATION I haeby affm unda pcnalty of pcrjury that I m cxmpt fiom thc CoilEctoB' Licmc llw for thc following @n (Se.7031.5. Buins ard Profsion Code): Any City or County which rcquL6 a pqmt to construct, altq. improvq &molish or rcpair uy' structue, prior to its issuocc, also rcquirG thc applicst for such pcmit lo filc a signcd st8t@ot thst hc or shc is licqEcd pGuut to thc provisiore of thc Contrrctor's Licenrcd taw (Chaptq 9. Commcncing with Sction 7000 of Division 3 of thc Bsins ed Prcfsions Code) or that hc or shc is ex@pt th@ftom sd the basis for thc allcged ampion. Any violatiotr of S6{ioo 703 1.5 by uy spplicantforapcrrnitsubjststhe applicmttoacivilpcmltyofnotmorcthefivchundreddollus($500). _1. u omo of thc [ropcrty, or my cmployc with waga s thcir rclc ompqution. will do thc woIt ed thc atnr-tuc b not intqdcd or offscd for sale (Sa.7044, Buirs md hofsiom Codq Thc Contrsctor's LiccE lrw do6 not apply to m oms of Ihc prcpgry who builds or iqFov6 th@n. ad who do6 zuch *ort hiroclf or h6clf or thrcugh his or ho om mploye, providcd that such improvffits rc rct intodcd or offcrcd for slc. I( howq, thc tuilding or inprovcrmt is rcld whhin one )qr of complaioo thc Ovos Buildq will havc ttE hrdq of troving thd he or drc dil rct tuild or impove thc popo'ty for rhc ptupos of elc). _1. os owner of the propfiy, am exclusively contracting with licensed contractors to construct thc projc.ct (Sec. 7044. Business and Profession 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 Contracto(s) licensed pursuant to the Contractor's License Law). -l am exempt under Section-, B. & P.C. for this reason. WORKERS' COMPENSATION DECLARATION I hereby affrrm under penalty of perjury one of the following declarations: _l have and will maintain a Certifrcate of Conscnt to Self-lnsure for workers' compensation, as provided for by Section 3700 of the Labor Code. for the performance of the work for which the permit is issued. #s;and will rnaintain workers' compcnsation insurance, as required by Section 3700 of the Labor Code, for the pcrformancc of fo5 which this peqnit is issued. My workers' compensation insurance carrier and policy number are: Aco A rrnori cctn 1- l-LL Policy _l cenify that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so .ls to become subject to the workers'compensation laws of California, and agrec that if I should become subject to the workers' cornpensation provisions of Section 3700 of the Labor Code. I shall. forthwith comply with those provisions. WARNING: Failure to secure workers' compensation coverage is unlawful. and shall subject an anployer to criminal penalties and civil frnes up to one hundred thousand dollars ($100.000). in addition to the cost of compensation, damages as provided for the .qb-l-- )r.n LICENSED CONTRACTOR DECLARATION I hereby affirrn under penalty of perjury that I arn licensed under provision of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Nurnber: -G-oo> ,rr", t^Z L{ - L( W I hcby affm undr poalty of perjury thst th@ is s corutructbn lcnding 8g6cy for thc pqfomocc of thc work for wldch thb pcrmit b issued (Sc. 3097, Civ. C.). [rnd6's Nmc: Lender's Address: APPLICANT DECLARATION I herEby affrnn under penalty of perjury onc of the follorving declarations: Dernolition Pennits-Asbestos Notification Federal Regulations (Title 40. Part6) KR"q, i.ed Letter o f Notification & ."nify that the federal regulations removalare not applicable to this project. the above mentioned property for inspection Applicant or Agent Pernritee nnnre the above I ,rrr,f-Z?-Z( Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/Ve nUI n s u lation Roof Sheathing Shear Wall Framing lnsulation/Energy Drwvall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif t t ,t a\.(rq FINAL qJ,I\'/ ,\T{Y(/ Certificate of Occupancy \ -\\7 \. Notes, Remarks, Etc. Date:_ _Expires: all City and County