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BUILDING. INSPECTOR RECORD SITE-WORK DATE ID/SIG COMMENTS Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf Ioor/VenVl nsu I atio n Roof Sheathinq Shear Wall Framing lnsulatio nlEnerqy Drywall Ext./lnt. Lath Brown Coat N/asonry Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif l^ r {7FINALov7lDfKTT Certificate of Occupancv Notes, Remarks, Etc. OWNERBUILDERDELCARATION *,1 ,*".]|[I hcreby affrm undcr pcnalty of perjury th.t I dn cxcmpt frcm the ConlracloE' Liccnsc hw for lhc following rca Busincss ond Profcssion Codc): Any Cily or County which rcquircs o pmit lo construcl, ulls. improve, dcmlish or rq;tr uny structurc, prior to its irsuancc, also rcquircs the applicant for such lErmil Io lile a signcd statcrrcnt that hc or shc is liccn$d putruant lo thc previsions of lhc Contractor's Liccn*d [aw (Chaptcr 9. Comcncing with S6tion 7000 of Division 3 of lhc Busincss ond PmfcssionsCodc)orthathcorsheiscxcmptthcrcfmmildthcbasisforlhcallcgcdcxcmption. AnyviolalionofSctionT03l.5byany applicrnt lbr a Jrcrmit subjccts thc applicant lo a civil pcnalty of not mrc than fivc hudrcd dollars ($500). _1. as owncr of thc propcrty. or my enrpl<lyecs with wagcs as lhcir solc comJrcnsatiort. will do thc work aml thc stnrcturc is not intendcd or ofl'crcd for salc (Scc.7044. Busirrcss and Professions Code: The Contraclor's Liccnsc l-aw docs not apply lo an owncr of thc proprty who builds or ilnprovcs thcrcrn, and who docs such work hinrsclf or hcrsclf or through his or hcr own enrployccs. providcd that such improvenrcnts arc not intcndcd or oftbred for sah. If. howcvcr, thc buikling or improverrnt is sold within one ycar of conrphtion, thc Owncr Buildcr will have thc burdcn of proving tturt hc or shc did not buih or improve the propcrty for tfrc purposc of sale). _1. as owner of thc proprty. um exclusivcly contracting with liccnscd contractors lo construct thc projcct (Scc. 7W, Business and Protbssion Codc: The Contractor's Liccnse Law docs not apply to an owncr of property who builds or improves thcrcon. and who contracts for such projects with a Contractor(s) liccnscd pursuant to thc Contractor's Licensc [aw). _l arn cxcrnpt B. & P.C. for this ffi nBCtlR,{TION I hcreby affirm undcr penalty of pcrjury onc of thc tbllowing dcclarations: _l havc and will maintain a Ccrtificatc of Conscnt to Self-lnsurc for workcrs' cornpcnsation. as provided for by Section 37fi) of the Labor Codc. for thc lrcrlbrmancc of thc work for which thc prmit is issucd. _l havc and will rnaintain workcrs' conrpcnsation insurancc. .ls rcquircd by Scction 3700 of thc Labor Code, tbr the pcrformancc <lf the work lbr which this pcrrnit is issucd. My workcrs' comlrcnsation insurancc carricr and Jrclicy nunrber arc: Policv Numbcr: Exoires: _l ccnify that in thc pcrformancc of thc work for which this pcrmit is issucd, I shall not cmploy any pcrson in any nlanncr so as to bcconrc subjcct to the workcrs' conrpensation laws of California. and agrce that if I should become subjcct to thc workcrs' comlrcnsation provisions of Section 3700 of thc [:hrr Code. I shall. tbrthwith comply with thosc provisions. WARNING: Failurc to sccurc workcrs' compcnsation covcragc is unlawful. and shall subjcct an employcr to criminal pcnaltics and civil lincs up to onc hundrcd thousancl dollars ($in addition to tltc cost of corttpcnsation. datnages as provided for thc Section 3076 Codc. intcrcst artd AlztO* I hercby affirrn undcr pnalty of pcrjury that I am liccnscd under provision of Chapter 9 (conmrcncing with Scction 7000) of Division 3 of thc Busincss and Profiessions Codc, and rny liccnsc is in full forcc and cflcct. Liccnse Class: License Numbcr: Dale:Conlractor:_ W I hcrcby afl-rm undcr lEmhy of lErjury lhat thcrc is a construction lcnding ugcrcy for thc perforrucc of thc work for which this psmit is issucd (Scc. 3097. Civ. C.). lrndcr's Nanrc: [,cndcr's Addrcss: APPLICANT DECLARATION I hcreby affmn undcr penalty of grerjury onc of the following dcclarations: Dcnrolition Permits-Asbestos Notification Federal Regulations (Titlc 40. Part6) -Required lrttcr of Notification \ _l ccrtify that thc fcdcral rcgulations rcgarding asbcstos rcmoval arc nol applicablc to this pmict. -l ccltig that I havc rcad rhis application and statc that the abovc informarion is corrcct. I agrcc lo comply with ail City and Counry ordinanccs and Statc rclating to building construction. abovc mcntioncd Applicant or Agent Pernritee nanre purrnses.f hcrcby authorizc represcntativefgrf this City and County lo cnter u;nn thc il , Datcrt Carricr:_