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BUILDING- INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcrcby allirm undcr pcmlty of pcrjury that I m cxcmpt frcm tlE Contraclon' Liccns liw for thc following rcamn (Sec.7031.5 Busincss ard Prcfcssion Codc): Any City or County which rcquircs a tEmh lo @nstrucl. altcr. improvc. dcmlish or rcltrir any structure, prior to its issuancc. alrc rcquircs thc applicant for such Jrcrmil to aile I sigrcd statcrcnt that hc or slrc is licensd puunt to thc prcvisions of tlrc Conractor's Lbcnsd [lw (Chaptcr 9, Comrcrcing with Scction 7000 of Division 3 of thc Business and Prcfcssions Codc) or that hc or shc is cxcmpt thcrcfrom und thc basis for thc allcgcd cxcmption. Any violation of Setion ?03 1.5 by sny applicBnt for 8 lrcrmit subjets thc applictrnt to a civil pcnalty of nol rurc tha[ fivc hundrcd dollus ($500). -1. as owncr oFthc propcrty. or my cmployccs with wagcs as thcir solc compcnsation, will do the work arxl thc structurc i.s not intendcd or ofFcrcd for sale (Scrc.7044, Busincss and Profcssions Codc: Thc Contractor's Liccnsc Law does not apply to an owner of thc propcrty who builds or improves thcrmn, and who docs such work himself or hcrsclf or through his or her own cmployces. providcd lhat such impnlvcnrcnts arc not intended oroffcrcd for salc. If. howcvcr. thc building or irnprovctncnt is sold within onc ycar of complction, thc Owner Builder will have thc burdcn of proving that hc or shc did not build or improve thc propcrty for thc purpsc of salc). -1, as owner of thc propcrty, am cxclusivcly contracting with licenscd contraclors to construct thc projcct (Scc. 7W, Busincss and Prrofession Codc: Thc Contractor's Liccnsc Law does not apply to an owncr of prolrcrty who builds or improvcs thcreon. and who contracts for such projccts with a Contractor(s) liccnsed pursuant to thc Contraclor's Licensc Law). -IamexenlptundcrScction-'B.&P.C.forthisrcason.Il.. r.,. EOETEsS:CQMPINSAIION DECI.ASAIIqN I hcrcby aftirm undcr pcnaltyofpcrjuryonc ofthc following dcltrations: -l havc and will rointain a Crnificatc of Conrcnt to Sclf-lnsurc for workcr$' @mlrnsation. as povidct for by SstioD 3700 of thc Labor Code, for tlrc prformne of thc work for which the Imit is issucd. $ L nu"" ona *ilf *intain workcrs' comlrnsation insurancc. rs rcquircd by Section 3700 of thc tnbor Codc, for thc pcrformrce oF thc work for this My workcrs'insurancc carricr and policy numbcr are: Policy (It a -l ccrtify that in thc pcrforrnancc of thc work for which this perrnit is issucd, I shall not cmploy any pcrson in any manncr so as to becomc subjcct to thc workcrs'compcnsation laws of California, and agrce that if I should bccomc subjccl to thc workcrs' compcnsation provisions of Scction 3700 of the [:bor Codc, I shall. lbrthwith comply with thosc provisions. WARNING: Failurc to sccurc workcrs' conrpcnsation covcragc is unlawful, and shall subjcct an employcr to crirninal pcnaltics and civil lincs up to onc hundred thousand dollars ($100.000), irr addition to of comgrcnsation. danuges as provirlcd for the attorney's fces. I hcrcby aff rrrn undcr pcnalty of pcrjury that I anr liccnscd undcr provisiorr (cornmcncing with Section 7000) of Division 3 ot' the Busincss and Prol'cssions Code. and my liccnsc is in t'ull frrrcc and cffcct. License Numbcr: ,[ 6 h( W I hcrcby sffirm undcr Jrcmliy of lrcrjury that lhcrc is a construction hnding sgcncy for thc pcrformncc of the work for which this lrcmit i! issucd (Sc. 3097, Civ. C.). lxndcr's Namc: [rndcr's Adtlrcss: APPLICANT DECLARATION I trcreby aftinn under pcnalty of pcrjury onc of thc following dcclarations: Dcrnolition Perrnits-Asbcstos Notification Fcdcral Regulations (Titlc 40. Part6) -Requircd lrttcr of Notification _l ccrtify that the tbderal rcgulations rcg:uding asbcstos rcmoval are not applicablc to this project. Wrccrtify that I have rcad this application and state thar thc abovc information is correct. I agrcc ro cornply with all City ancl Counry ordinances and Statc Laws rclating to building construction.rcprcscntatives of this City and County to cnlcr uJxrn thc abovc rrrcntioncd propcrly l'or inspcction purposcs.0nApplicant or PcmllE Em (DrlDl): Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf !oor/Ve nUI ns u I atio n Roof Sheathinq Shear Wall Framing *l$tht lnsulatio nlEnergy Ql,Q,I ,l-A k) Drywall d/,7b,'l\lo Ext./lnt. Lath //tv Brown Coat I Masonry Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif I FINAL ?/tft, Certificate of Occupancv I I l// Notes, Remarks, Etc. 0wner: Contractor:_ ,Jofa