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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG COMMENTS OWNER BUILDER DELCA RATION I hcrcby affirm under Jrcnalty of pcrjury that I am exempt from thc Contractors' License [:w for thc following reason (Sec.7031.5 Busincss arxl Profession Codc): Any City or County which requircs a pcrmit to construct, altcr. irnprove, derrnlish or rcpair any structurc, prior to its issuancc, also requircs the applicant for such pcrmit to file a signcd statcmcnl that hc or shc is liccnscd pursuant to thc provisions of thc Contractor's Liccnsed Law (Chapter 9, Commencing with Sc.ction 7000 of Division 3 of thc Businegs and Profcssions Code) or that hc or shc is excnpt thercliom ard thc basis for thc allegcd cxentption. Any violation of Scction 7031.5 by any applicant for a Jrcrmit subjccts thc applicant to a civil penalty of not morc than five hundred dollars ($5001. -1. as owlrcr of the propcrty. or my employccs with wages as thcir sole compensation. will do the work and thc strtlcturc is rnt interxlcd or offercd for salc (Scrc.7o44, Busincss and Profcssions Codc: The Conlraclor's Liccnse law docs nol apply to an owncr of the proJrcrty who builds or inrprovcs thcrcou and who docs such work himself or herself or through his or her own employecs. providcd that such improvcnrcnts arc not intcrdcrl oroffercd for salc. lf. howerrcr. thc buikling or inprovcnrcnt is sold wilhin onc )aat of comphtiorL thc Owrrcr Builder will havc thc burdcn of proving that he or shc did not build or improve thc pnoprty for ttrc purynse of sale). _1. as owncr of thc proprty. am exclusivcly contracting with licenscd contraclors to construcl lhc projcrcl (Scc. 7044, Business and Professkrn Code: Thc Contraclor's Liccnse Law docs not apply to an owner of propcrty who builds or improves thcrcon. and who contracts fbr such projccts with a Contractor(s) liccnsed pursuant to the Conlractor's Liccnse hw). -IamcxcmptundcrScction-,B.&P.C.forthisrcason'Date: 0wner:_ WORKERS' COMPENSATION DITCLARATION I hereby affirrn under penalty of pcrjury onc of thc following dcclarations: _l havc andwill maintainaCertiticateof Conscnt to Selt'-lnsurc for workcrs'conpcnsation, as provided for bySection 3700of the labor Codc. du"ono for thc perftrrnunce of thc work for which thc pcrmit is issued. will maintain workers' c<lrrrpcnsation Section 3700 of the [:bor Code. for the pcrformarcc of this is issued.carrier and policy number are: 3-)N 2 I _l certify ttrat in thc pcrformancc of thc work for which this pcrrnit is issucd. I shall not so as to bcconrc subjcct to thc workers'conpcnsation laws of California. and agrce that if I employ any person in any manncr should becornc subject to ttrc t workcrs' compcnsation provisions of Section 3700 of the latnr Code. I shall. lbnhwith comply with thosc provisions. WARNING: Failure to sccurc workers' compensation covcrage is unlawful. and shall subjcct an ernploycr to criminal pcnaltics and civil fincs up to onc hundred thousad dollars ($100,000), in addition to lhe cost of conqrcnsation. damagcs as providcd for thc 3 of thc Business and Professions Code. arxl my liccnse is in full forcc and cffect. C(INS'IRT)CTION I,IINDIN(; A(;ENCY I herchy aflirm urder Fnulty of Frjury that thw is a @nstruction hnding agcrcy for thc Jtrfort1rme of the work for which this Frmit is issucd (Scc. 3097. Civ. C.). lrndcr's Nanrc: l.ender's Ad&ess: APPLICANT DECLARATION I hcreby affrrm undcr pcnalty of prjury onc of thc following dcclarations: Derrrolition Pcrrnits-Asbestos Not ification Federal Regulat ions (Titlc 40, Part6) -Requircd l,etter of Notification ffiffi ffid;-:-dffi;;il'#il**,***** *Y",* above nrntioncd proprty for /ttpplitarrr or Agenl [ermilee name *r",(o ->jl--2D Set Backs Forms/Stee!/Holdowns Erection Pads UFER Ground SLAB Floor Subf loorlY enV lnsulation Roof Sheathinq Shear Wall Framinq lnsulatio nlEnergy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req. Deputy Final Report Enqineer Final Report Flood Zone Certif . FINAL /Q-11/aa n ,4r.lA Certificate of Occupancy Notes, Remarks, Etc Rev. 08-07-201 5 .l L C 6- Zo conrracror:_