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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUIIDER DEI,CARATION I h6cby affm unda pcnalty of pcrjury that I m qmpt from thc Coilretos' Licw law for thc following wn (Se.7031.5 Buine fld Profeion Codc): Any City or County which rcquic a panit to @Ntrucl, alta, imprcvg <hnolirh or rcpair uy structre, prior to its issuuce. also rcquirc thc applimt for such p6mit to fib a stocd statmot thar hc or slE b licqEcd plMt to thc provieioE of thc Conirtrtor's Licmsed kw (Chapt6 9, Comming with S6tion 7000 of Divisirn 3 of thc BBin6 ed Prcfsions Codc) or that hc or shc is qmpt thqcfrom ad thc b6is for thc allcgcd cxmption. Any viotatioo of Sction 7031.5 by uy applicmtforapcmitsubjctsthc appticmttoacivilpcultyofootmorcthefivchundrcddollrs(t500). _1, as owner of the propefiyr or my employecs with wages as their sole compauation. willdo thc work and the structurc is not intended or offered for sale (Sec.7044. Business and hofessions Code: The Contractor's Licensc Law does not apply to an owner of the property who builds or improves theron. and who does such work himself or herself or through his or her own employecs. providcd that such funprovanents are not intendcd or offcrod for salc. I[, howener, thc building or imp,rovement is sold within onc ]â‚¬ar of complaion. thc Orvncr Builder will have the hrdcn of proving thd he or she did not build or improve the propcrty for the purposc of sale). -1. as owner of the property, arn exclusively contracting with licenscd contractors to construct the project (Sec. 7044, Bwiness and Pnofession Code: The Contractor's License Law does not apply to an owner of properly who builds or improves thereon, and who contracts for such projects with a Contracto(s) licorscd pursuant to the Contractor's Liccnse Law). -l am exempt under B. & P.C. for this reason. Date:_ Owner: WORKE R.S' COMPENSATION DECLARATION I hereby affirm under peoally of perjury one of the following declarations: _l have and will maintain a Certificate of Consent to Sclf-lnsure for workers' compensation. as provided for by Section 3700 of the Code, for the performance of _l certi& that in the performance of the work for which this permit is issued, I shall not cmploy any person in any manner so as to bccome subject to the workcrs'compeirsation laws of California, and agree that if I should become subject to the workers' compensation provisions of Secrion 3700 of the Labor Code I shall. forthwith comply with those provisions. WARNINC: Failure to secure workers' compensation coverage is unlawful, and shall subject an onployer to criminal penahies and civil fines up to one hundred thousand dollars ($100,000). in addition to the cost damages as provided for the Section 3076 Code, interest and attorney's fecs. l)lc('t,All^'l'l()N I hereby affrm under penalty of perjury that I am licenscd under provision 9 (commencing with Section 7000) of Division 3 of the Busincss and Professions Code, and my license is in full force and effcct. Number: q?B 3r5 Conrracror: ?zvtn I fâ‚¬ â‚¬rlqrcq7W I hrcby affm udo pcnalty of pcjury thst th@ is 8 @nstruc,tion lcnding ag6cy for thc pqforrmcc of thc rcrk fur which thb pqmit b issucd (S*. 3097, Civ. C.). Lender's Narne: koder's Addrcss: APPLICANT DECLARATION I herfu aftirm undcr pcnalty of pcrjury one of the following dcclarations: Dcmolition Pcrmils-Asbcstos Notification Federal Regulations (Title 40, Part6) -Required Lettcr of Notification with all City and County Appficant or Agent \Permitee nsme (print): and to cnter upon thc Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloor/Ve nul n s u Iatio n Roof Sheathinq Shear Wall Framing lnsulation/Enerqy Drywall Ext./lnt. Lath Brown Coat Masonry / Pool Fence \ T-Bar Handicap Req \ Deputy Final Report Engineer Final Report Flood Zone Certif. FINAL /0-(-2 I /Z C,a %2tl Certificate of Occupancy Notes, Remarksl Etc. t (r ^-ri ^ - \and policy number are: Poricy*rr*r, {too-\\3 Expires: - L\