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BUILDING- INSPECTOR RECORD SITE-WORK DATE ID/SIG COMMENTS OWNER BUILDER DALCARATION I hercby offtrm undcr penalty of pcrjury thal I m cxctrrpt frcm thc ContodoB' Liccn* bw for thc followhu rcasn (t'.7031.5 . Busincss and Profcssion Codc): Any City or County whhh rcquires a JErmit to consruct, ahs. imprcve, dcmlish cr rEpair my structurc, lrior to its issuancc, alm rcquires thc applicant for such Frmit to file a signcd statcrcnt that hc or she is liccnsd puzuilt to thc pmvisions of thc Contractor's Liccnsd kw (Chrylcr 9, Comrcncing wilh Section 7000 of Division 3 of lhc Busircss and Prcfcssions Codc) or that hc or shc is excmpt thercfrom and lhc basis for lhe allcgcd cxcmplion. Any violation of Scctbn 703 1.5 by any applicunt for a pcrmit subjcts the applicant to a civil pcmlty of not morc than fivc hundrcd dolles ($50O). _1. as owncr of the propcrty. or my employees with wages as their solc comlrcnsation. will do thc work and tlrc stnrcturc ls not intendcd or offercd for salc (Scrc.7o44. Business and hofessions Codc: The Contractor's Licensc [.aw docs not apply to an owncr of the propcrty who builds or improvcs thcreon, and who does such work hinrsclf or hcrself or through his or hcr own employees. providcd that such improvcnrcnts are not intcnded or offcrcd for salc. If, howcvcr. thc building or improvcnrtlt is sold within onc ycar of complction, thc Owner Buildcr will have thc burdcn of proving that hc or shc did not build or improvc tlre propcrry for thc purynsc of salc). _1. as owncr of thc propcrty. atn cxclusivcly contracting with liccnsed conlractoni lo construct thc project (Scc. 7M4. Busincss and Profcssion Codc: The Contractor's Licensc Law docs not apply lo an owner of progrcrty who builds or improvcs thcrcon. and -I who contrilcts for such projects with a Contractor(s) liccnscd pursuant to thc Contractor's License Law). & I'}.C. for this rcaton. WORKI.' RS' CONI IDI'NSA'II( )N DECLARATION I hercby affirm undcr pcnalty of perjury onc of the following dcclarations: _l havc and will rnaintain a Certificate of Consent to Self-lnsure for workers' conlpcnsation, as providcd for by Section 3700 of the labor Codc. for the pcrformancc of thc work for which the pcrnrit is issucd. _l havc and will maintain workcrs' cotnpensation insurancc, as rcquircd by Scction 3700 of thc Labor Codc, for thc pcrformancc of thc work for which this pcrmit is issued. My workcrs' compensation insurance carricr and plicy number arc: Policy _l ccrtify that in thc performancc of thc work for which this pcrmit is issucd, I shall not cmploy any pcrson in any ntanner so as to bcconrc subjcct to thc workers' compensation laws of California. and agrce thut if I should becomc subjcct to thc workcrs' comlrcnsation provisions of Scction 3700 of thc [:bor Code. I shall. forthwith comply with thosc provisions. WARNING: Failure to sccurc workcrs' compensation coveragc is unlawful. and shall subjcct an employcr to criminal pcnaltics and civil fincs up to onc hundrcd thousand dollars in addition to thc cost of conrpcnsation, danutges us providcd lbr the Section 3076 of thc intcrcst and ) DF'CLARATION I hcrcby affirm undcr pcnalty of pcrjury that I am liccnsc<l under provision of Chaptcr 9 (comnrcncing with Scction 7m0) of Division 3 of thc Busincss and Profcssions Codc, and my liccnsc is in full forcc and etfect. Licensc Class: Liccnse Number: Date: W I hercby atfirm undcr Fnalty of Frjury that thrc is a @nstructk n hnding ugency for thc pcrformne of thc work for which this lEmit is issucd (Scc. 3097. Civ. C.). Lrndcr's Addrcss: APPI ICANT DECLARATION I lrreby affrrm undcr pnalty of prjury one of thc following dcclarations: Dcmolition Permits-Asbestos Notification Fcderal Rcgulations (Titlc 40, Part6) -Rcquired lrtter of Notification _l\Cgify that thc fcdcral rcgulations regarding asbestos rcnnrvalare not applicablc to this projcct. _l ccrlity that I havc rcad this npplication and stalc lhat thc atnvc irtfornration i all City and County ordinanccs and Statc [-aws rclating to building construction. and hcrcby authorizc upn thc above rncntioncd propcrty for Applicant or Agent I'crnritce nnnle purF)ses.0 to ) Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenVl n su I atio n Roof Sheathinq Shear Wall Framinq lnsulatio nlEnergy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputv Final Report Enqineer Final Report Flood Zone Certif lr A FINAL tst [0.\'7,\bt4.if C { Certificate of Occupancy I l Notes, Remarks, Etc Data -Expires: Contractor:- (nrilrl):