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BUILDING. INSPECTOR RECORD SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DEI'ARATION I hoeby aflim undo poalty of pcrjury that I m cxcmpt from thc ContractoB' Licffi law for the following rcen (Se.7031.5 Businss md Profession Codc): Any City or County which require a pomit to congruct. alt6. improvc, dcrnolish or repair uy struclue. prk r to its isuocc, also rcquirs thc applicut for such pcmit to filc a sigocd statmmt that hc or slrc b liccnsâ‚¬d ptNilt . to thc provisioE of thc Contractor's Liccnscd Law (Chapts 9, Commcncing with Setion 700O of Division 3 of thc BNincs ed Profsions Codc) or that hc or shc is exempt thsefrom od thc bosis for thc allcged empion. Any viol.tion of Sdtion 7031.5 by uy applicantforapemitsubjCtsthc applic8nttoacivilpcnaltyofnotmorcthmlivchundreddollrs($500). -1, as owner of the property, or my employees with wages as their sole cornpensation. will do tlie work and the structure is not intended or offcred for sale (Sec.7044, Business and hofessions Code: The Contractor's License Law does not apply to an owner of the prrrperty who builds or improves thereon. and who does such work himself or herself or through his or her own employees, provided that such improvonents are not intended or oflired for sale. I[, however. the building or improvement is sold within onc ]car of complaion. the Or,vner Builder will have the hrden of proving that he or shc did not build or improve the property for the purposc of salc). -1, as owner of the property. am exclusively contracting with licensed contractors to construct the pro.iect (Sec. 7M4. Business and Profcssion 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 Contractor(s) licoued pursuant to the Contractor's License Law). I arn exemot P.C.reason. Datc t DECI,ARATION I hereby affrrm undcr penalty of perjury one of the following declarations: -l have and will maintain a Certificatc of Conscnt to Self-lnsure for workcrs' comperuation. as p,rovided for by Section 3700 of the Labor Code. lbr the performancc of thc work for which the perrnit is issucd. -l have and will maintain workcrs' compensation insurance. as required by Section 3700 of the Labor Code. for thc performancc of the work for which this p,ermit is issued My workers' compcnsation insurance carrier and policy number are: any manner to the rvorkers' compersation provisions of Section 3700 of the Labor Code, I shall.rvith those provisions. WARNING: Failure to sc'cure workers' compensation coverage is unlawful.shall an anployer to criminal penalties and civil fines up lo one hundred thousand dollars ($100.000). in addition to of compensation. darnages as provided for the Section 3076 L:bor Code. interest and attorncy's fecs.2 It DECI.ARATION I hereby affirrn under penalty of perjury that I am licensod under provision of Chapter 9 (comnrencing with Section 7000) of Division 3 of the Business and Professions Code. and my license is in full force and effect. Licensc Class:_- License Numbcr: W I h@by 8ffm undd pcnslty of pcrjury thsr th@ is a construclbn lcndiry agocy for thc po fommcc of thc rcrk for which rhis p6mil b issucd (S(. -1097, Civ. C.). lrndd's Nmc: I-ender's A<Jdress: APPLICANT DECLARATION I hoeby affinn under penalty of pcrjury one of the following declarations: Dernolitron Pcrmits-Asbcstos Notification Federal Rcgulations (Title 40. Part6) ___ _Required l,etter o f Notification with all City and County and above nrentioned properly for inspection rtpplicnnt or Agent a 2 cnter upon the Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloor/Ve nUI nsu latio n Roof Sheathing Shear Wall Framing lnsulation/Enerqy Drynruall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif ,A FINAL l6-{-A \lJD,r)trl\ Certificate of Occu Notes, Remarks, Etc. -+ Dale:( orrl raclor. Permitee name lprinrl:-*- - Date:_