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2 BUILDING- INSPECTOR RECORD SITE.WORK DATE ID/S!G.COMMENTS Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Subf loo rlV enV lnsulation Roof Sheathing Shear Wall Framing lnsulatio nlEnerqy Drywall Ext./lnt. Lath Brown Coat ltlasonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif ,/\ FINAL q-A-7^V.TL\1 Certificate of Occupancy \-/ Notes, Remarks, Etc. owNER BUILDER DELCARATIoN 'ID Il tI hcrcby afhrnr under penalty of pcrjury that I am exempt from the Contractors' Liccnse Lrw for the following rctrson (Sec.A3l.5 Busincss and Profession Codc): Any City or County which requircs a ;rrmit lo construct, alter. improve. demolish or rcpair any structurc. prior to its issuancc. also rcquircs the applicant f<rr such Jrcrmit to filc a signcd statcment that hc or she Ls licenscd pursuant to thc provisions of thc Contractor's Licenscd L:w (Chaptcr 9. Comnrcncing with Scrction 7000 of Division 3 of the Busincss and ProfcssionsCode)orthathcorshciscxcmptthcrcfrornandthebaslsforthcallegcdcxcmption. AnyviolationofSectionT03l.5byany applicant for a pcrmit subjcrts thc applicant to a civil pcnalty of not morc than five hundrcd dollars ($5001. _1. as owncr of thc propcrty. or my cmployccs with wagcs as their solc compcnsation, will do thc work and thc stnrcturc ls nrt intcndcd or offercd for salc (Scc.7044, Busincss and Professions Code: Thc Contractor's License l-aw dcres not apply lo an owner of thc property who builds or improves thcrcon and who does such work himsclf or hcrself or through his or hcr own employces. provided that such improvcnrcnts are not intcndcd oroffercd for salc. lf. howewr. thc buiHing or inprovenrent is rcld wilhin onc ycar of complction, thc Owncr Builder will have thc burdcn of proving that hc or she did not buikl or improve the propcrty for tlrc purpose of salc). _1. as owner of the profrcrty. am exclusivcly contracting with liccnsed contraclors to construct thc project (Scc. 7U4, Busincss and Prrofesskln Ctxle: Thc Contractor's Liccnse Law docs not apply to an owncr of proJrcrty who builds or improvcs thercon, and who contracts lbr such projects with a C-ontractor(s) liccnscd pursuant to thc Conlractor's Licensc Law). _.1 rrn cxcnlpl undcr B.& Date:(-.- lt l^' ' DECLARATION I hcreby affirm urrder Jrcnalty of perjury one of thc following dcclaratiorrs: _l havc and will maintain a Ccrtificatc of Conscnt to Self-lnsurc for workcrs'compensation. as ;novided for byScction -1700 of thc l.ahor Codc. for the performance of thc work for which the permit is issued. _l havc and will maintain workcrs' compensalion insurarcc, as rcquircd by Section 37fi) of thc Labor Codc, for thc pcrfornuncc o[ thc work for which this pcrmit is issucrl. My workcrs' comJrcnsation insurarrce carricr and plicy numbcr arc: Policy Nurnbcr: Expircs: _l ccrtify that in thc pcrforrnance of thc work for which this pernrit is issued. I shall not employ any pcrson in any manncr so as to bccomc subject to the workcrs' compcnsation laws of Califomia. and agrcc that if I should bccornc subjcct to thc workers' compcnsation provisions of Section 3700 of the l-abor Code. I shall. forthwith comply with thosc prcvisions. WARNING: Failurc to sccure workcrs' compensation covcrage is unlawful, and shall subject an employer to criminal ;rcnaltics and civil fincs up lo one hundred thousand dollars ($100,000), in addition thc of conqrensation. danragcs as provided for thc allorney's I hcrcby aflirrn under prralty ol'prjury that I arn liccrrsed 9 (comrncncing with Scclion 7fin) of Division 3 of the Busincss and Professions Code. and nry licensc is in full force and cffcrt. Liccnse Class: Licensc Numbcr: Date:- W I hcrcby aflirm undcr Fnaltyof lErjury lhat therc is a @nstruction lcnding agcrcy for thc pcrfornmcc of thc work for which this lrcrnlit is issucd (Scc. 3097. Civ. C.). Lcndcr's Namc: kndcr's Address: APPLICANT NECLAITATION I trcrcby aflinn undcr pcnalty of perjury one of the following dcclarations: Demolition Pcrnrits-Asbcstos Notification Fedcral Rcgulations (Titlc 40. Part6) _Rcquircd lrtter of Notification -l ccrtify that thc fcderal rcgulations rcgarding asbcstos rcnnvalare not applicable to this projcrt. { -l ccrtify that I have r"u.t tilliupplicarion and state thut thc atnve infornration is conccr. I agree ro comply with all Ciry jd County ordinanccs and Statc laws relating building constructioru and herchy authorize rcprescntatives of this City and Counly to enler uJxrn the abovc rrrcnlioncd propcrty ltrr Applicanl or Agent Pernrilee nanre D a 0B-07-201 5 Ptrrnv