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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcrcby aflirm undcr Jrcnalty of pcrjury that I u excmpt fDm thc Contrrcton' Licensc law for lhe folbwing rcen (58.7031.5 Busincss ard Profcssion Codc): Any City or County which rcquires a ymmil to construct, altcr, improvc, dcrclish or rcJEir any structurc, prior Io ils issuilce, also rcquircs lhc applicant for such lf,rmit to filc r signcd statcmnt that hc or shc is lienrcd pusuant' to thc prcvisions of the Contrrctor's Liccnsd llw (Chapicr 9. Commcncing with Sfftion 7000 of Division 3 of fte Busircss and ProfcssionsCodc)orthalheorshciscxcmptthcrcfrcmandthebasisforthcsllcgcdexcmption. AnyviolationofStrtionT03l.5byany applicatrt for a pcrmit subjets thc spllicant to a civil pcnalty of not mrc th.n five hundrci dollus (5500). _1. as owncr of the propcrty, or my employccs with wagcs as thcir solc compcnsation. will do thc work arxl thc stnrcturc is not intcndcd or oll'crcd for salc (Sec.7044, Busincss and Professions Codc: Thc Contractor's Liccnsc Law docs not apply to an owner of the propcrty who builds or improves thcrcnn. arxl who docs such work hirnsclf or hcrsclf or through his or her own crnployccs. providcd that such improvcments arc not intendcd or offcred for salc. If, howevcr, thc building or improvcnEnt is soh within one ]rcar of comphtion. thc Owner Buildcr will havc thc burden of proving thal trc or shc did not build or improvc thc propcrty for the puqxrsc of sah). -1. as owncr of thc propcrty, arn cxclusivcly contracting with liccnscd contractors lo conslruct thc proict (Scc. 7W. Busincss and Profession Codc: Thc Contraclor's Licensc Law docs not apply to an owner of propcrty who builds or improvcs thcrcon, and who conlracls for such proicts with a Contractor(s) liccnscd pursu&nt to thc Contractor's Licensc L:w). I arn excmnt section-,ffi,W*ut--Ornnaa'X I hercby affirm under pcnalty of pcrjury onc of thc following dcclarations: _l have and will maintain a Ccrtificatc of Consent to Self-lnsure for workcrs'compensation. as providcd for by Scction 3700 of the I-abor Codc. for the pcrfornunce of the work for which the pcrmit is issued. -l havc and will maintain workcrs' compcnsation insurancc. as requircd by Scction 3700 of thc Labor Codc. for thc pcrformance of lhc work for which this permit is issued. My workers' compensation insuruncc carrier and policy number are: Policv Number: Exoires: -l ccrrify that in thc pcrformancc of thc work for which this pcrrrrit is issucd. I shall not cmploy any [rcrson in any manncr so as to bccornc subjcct to thc workcrs'compcnsation laws of California, and agrcc that if I should become subjcct to the workcrs' cornpcnsation provisions of Section 3700 of the L:tnr Codc, I shall. forthwith cornply wilh thosc provisions. WARNING: Failurc to sccurc workers' compcnsation coverage is unlawful, and shall subject an cnrployer to criminal pcnalties and civil fincs up to one hundrcd thousand dollars ($100.000). in addition to the cost of compcnsation. damages as provided for the attorrrcy's fees. I hcrcby affirrn undcr penalty of pcrjury that I arn licenscd undcr 9 (commencing with Scction 7000) of Division 3 of the Business and Professions Code. and nry license is in full force and cffect. Liccnsc Class: Liccnsc Numbcr: Contractor: CONS'I'RU("1'l():r- I UNDING A(i UNCY I hcrcby affirnr undcr pnalty ofpcrjury that there is a constructior lcnding agcncy for thc pcrfornuncc ofthc work for which this JErmit is issued (Se.c. 3097, Civ. C.). lrnder's Name: Lcndcr's Addrcss: APILICAITT.DECI.ASATON I horby atrm undcr penalty of pcrjuy onc of thc following delsrstions: Dcmlition Pcrmits-Asbcstos Notifiotion FcdcBl Rcgulations (Titlc ,lO, Part6) Rmuircd [rtIcr of Ndifretion -l certify that the fctcral rcgulations rcgarding ubcstos rcrcval uc not applicable to this pmixl , fld.l ccnify rhat I h8rc rc{d this application atd state that the abow inforrotion is corcct. I agrc to @mply with all City and County lordinanccs sd State Lrws Elsting to building constuction, std hercby authorirc rcprercntalires of ihis City and County to ents upon thc above rncntioncd propcrty for inspection Applicanl or Agent lDernrilec nanle a Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenVl nsu lation Roof Sheathing Shear Wall Framing lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat N/asonry Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif . I 4) F!NAL IPI(L]f *A*rdL y7 Certificate of Notes, Remarks, Etc \J -) Date: