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BUILDING. INSPECTOR RECORD SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION - .AI hcrcby aftirnr under pcnalty of pcrjury that I am cxcnrpt frorn thc Conlractors' License [:w for thc followirfg.ca*r,n[031,.5 Busincss arxl Profession C<ilc): Any City or County which rcquires a pcnnit to construct. alter. improve. dcmolish or [pir any structurc, prior to its issuancc, also requircs the applicant for such permit to file a signed stalenrent that hc or shc is licenscd pursuant to the provisions of thc Contractor's Licensed Law (Chaptcr 9. Commcncing with Sc',ction 700O of Division 3 of the Business and Professions Codc) or that hc or shc is cxcrnpt thcrcfronr and thc basis for thc allcgcd cxcmption. Any violation of Scction 703 I .5 by any applicant for a pcrrnit subjccts thc applicant to a civil pcnalty of not morc than fivc hundrcd dollars (55001. -1. as owncr of thc profreny. or my employecs with wages as thcir rclc compcnsation, will do thc work arxl the structurc is rnt intended or offcred for sale (Scrc.7044, Business and Profcssions Codc: The Contractor's Liccnse law does not apply to an owner of the propcrty who builds or improves thereon. and who docs such work hinrsclf or hcrself or through his or her own employecs. providcd that such improvenrcnl.s arc not intcndcd oroffcrcd for sah. lf. howcvcr, thc building or inprovenrcnt is sold within onc year of completion, lhc Owncr Buildcr will havc thc burdcn of proving that hc or she did not build or inprove ttrc propcrty for the purgnse of salc). __1. as owncr of thc proprty, amexclusivcly contracting with licenscd contractors to construct thc projcct (Scc. 7W. Busincss and Profcssion Code: Thc Contractor's Liccnsc Law docs not apply to an owncr of propcrty who builds or improves thcrcon. and who contracls for such projccts with a licenscd pursuant to thc Contraclor's Liccnsc [aw). _l arrr undcr B. & P.C. Date:--- DECLAITATION I hcrcby affirm under penalty of pcrjury onc of thc following dcrlarations: __l havc and will mlinlain a Ccrtilicatc of Conrcnt to Sclf-lnsurc [<rr workcrs'corrrpcnsation, as providcd for byScction 37fi) of the Labor Codc. for thc pcrformancc of the work for which thc pcrmit ls issucd. _l have and will maintain workers' comJrcnsation insurarrce, as rcrluired by Scction 3700 of the labor Code, for the performarce of thc work for which this pcrmit is issued. My workcrs' compensation insurancc carricr and plicy numbcr arc: Policy Numbcr: Expircs: _l ccrlify that in thc pcrforrnancc of the work for which this pcrmit is issucd. I shall not enploy any pcrson in any rnnner so as to beconrc subjcct to thc workcrs' compcnsation laws of California. and agrce that if I should beconrc subjcct to thc '.' workcrs' compcnsation provisions of Scction 3700 of the l-abor Code. I shall. forthwith comply with thosc provisions. WARNING: Failurc to sccurc workcrs' compcnsation covcragc is unlawful. and shall sub"|cct an crnploycr to crinrinal pcnalties and dollars ($addition to thc cost of comgrcnsation. damagcs as providcd for thc attd altorrrcy's I hcrcby allirnr umlcr pcnalty of pcrjury lhat I am licenscd 9 (comnrcncing with Sc,ction 7000) of'Division 3 of the Busincss and Profcssions Codc, and my liccnse is in full forcc and cftcct. Liccnsc Class: l,iccnsc Nurnbcr: Dale:_Contractor:_ W I hcrcby aIlirm undcr ;rnohy of 1Erjury that thcrc is . @nsiructk n lcnding sgercy for the Frforlrc of thc work for which this Jrcmit is issued (Scc. 3097. Civ. C.). lindcr's Narc: l-cndcr's Addrcss: APPLICANT NECLARATION I hocby af irm undcr pcnalty of perjury one of thc following dcclarations: Dcnrolition Pcrmits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40, Part6) _Rcquircd [rttcr of Notification -l certity that thc fedcral rFguhtions rcgarding asbcstos renmvalarc not applicable to this projcct. _l cenify that I havc read this with all City and County and County lo enter u[r)n thcordinances and State laws rclating abovc nrcntioncd propcrty for Applicant or Agenl Permitee name Dil", t)f ) /).o Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/Venvl ns u I atio n Roof Sheathing Shear Wall Framing lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat [Vlasonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif n FINAL 1.27-Z uurfyJ Certificate of Notes, Remarks, Etc. Rev. AB-07 -201 5 - Owner:- I