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BUILDING. INSPECTOR RECORD SITE-WORK DATE ID/SIG.COMMENTS OWNER AUILDER DELCARATION I hcrcby affirm undcr pcnulty of Frjury th.t I M cxcmpt frcm thc Contractos' Liccnse tiw for thc following rcastr (56.7031.5 Busincss and Profcssion Codc): Any City or County which rcquircs a ;rcrmit lo construcl. oltcr, improvc, dcmlish or rcpir any slruclurc. prior to its issuarce, alm rcquircs thc applicant for such Frmil to filc a signcd statemnt lhat hc or slrc is liccnscd pursuanl to Ihc pmvisions of the Contractor's Licenrcd law (Chaptcr 9, Conmcncing with Scction 7000 of Division 3 of thc Busincss md Pmfcssions Codc) or that hc or shc is cxcmpt thrcfrom Bnd thc bosis for thc allcgcd cxcmption, Any violation of Setion 7031.5 by any applicant for a lErmit subjets thc applicant lo a civil pcnally of not morc thM fivc hundrcd dollus ($500). _1. as owncr of thc prof,crty. or my employccs with wagcs as thcir solc cornpcnsation. will do thc work and thc structure is not intcndcd or olfcred tbr salc (Sec.7044, Busincss and Professions Code: Thc Contraclor's Liccnse l-aw docs not apply to an owncr of thc proJrcrty who builds or impmvcs thcreon, and who drrcs such work hintsclf or hcrsclf or through his or hcr own employccs. providcd that such improvcnrcnts arc not intcndcd or offcrcd lbr sale. lf. howcver, thc building or improvcrpnt is sold wilhin one ycir of cornplction, the Owncr Builder will have the burdcn of proving tlut he or shc did not build or improvc the propcrty for the purynsc of salc). X. u:; owncr of the profrcrty. am cxclusivety contracring with licensed contraclors to construct rhc project (Scc. TW4,Busincss and Prrolbssbn Codc: Thc Contraclor's Liccnse Law docs not apply to an owncr of propcrty who builds or improvcs thcrcon. and who contracts for such projccts with a Contracto(s) liccnscd pursuant to thc Contractor's Liccnse t aw). _l arn cxcnlpt undcr B. & P.C. for this reason. I 1,. r,,. WORKERS' COMPF'NSATION DECLARATION I hcreby afTirm under penalty of pcrjury onc of the following declaralions: _l havc and will maintain a Certifrcatc of Consent to Self-lnsure for workers' compcnsation, as provided for by Section 3700 of thc Labor Codc, for the pcrformance of the work for which the pcrmit is issucd. !6 nuu" una thc work lirr Scction 3700 of thc Labor Codc, for thc pcrlbrmancc of carricr and plicy numbcr are: vawt poricyN,,,b",, ?U!-v/c tL? t.'(t Expircs: -l ccrtify that in thc pcrformancc of thc work for which this pcrrnit is issued, I shall not employ any person in any manncr j so as to bccorrc subjcct to the workcrs' compensation laws of Califbrnia. and agrce that if I should bccome subjc-ct to thc workcrs' compcnsation provisions of Section 3700 of thc Lahor Codc. I shall, forthwith comply wilh thosc provisions. WARNING: Failurc to sccurc workers'compcnsation covcrage is unlawful. and shall subjcct an civil fines up to onc hundrcd thousand dollars (Slfi).000). in to thc cost o[as provided for the "Scction 3076 of thc Labor Codc. intercst and allorncy's a\ fl.rla.I vv\e 1) , 7o Ll DECLARATION I hcrcby atfirnr undcr pcnalty of pcrjury lhat I am liccnrcd undcr provision of Chaptcr 9 (conuncncing with Scction 7000) of Division 3 of thc Business and Profcssions Code. and my liccnse is in l'ull f<rrcc and cft'ect. Licensc class: B C 31 Liccnse Numbcr:b91yq Date: J wna 71, 7da I a?J tpt I a W I hcrcby allirm undcr pnrlty of lrcrjury that th@ is a construction lcnding rgcncy for lhc performrcc of thc wrk for which this Fmit is i$sucd (Sc. 3097, Civ. C.). Lrndcr's Nam: lrnder's Addrcss: APPLICANT DFCLARATION I hcreby a.ffinn undcr pcnalty of pcrjury one of thc following dcclarations: Dcmolition Pcrmits-Asbcslos Notification Fcdcral Rcgulations (Titlc 40. Part6) -Rcqu ircd lrtter of Notification -l ccrtify that thc fcdcralregulalions rcgarding asbcstos rcntovalare not applicablc lo this projcct. _l ccrtify that I have read this application statc that the atnve inlormalion is corrccl. I agrcc to cornply with all City and County ordinanccs and State [:ws rclating to of this City and County to enter upn thc alxrvc nrcntioncd propcrty for inspcction Applicant or I)rrntitcc arxl -1 A c'r^( z(?-oU Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/Ve nt/l nsu I ati o n //t/4 Roof Sheathing v/7/d/kfirurt wv Shear Wall / rt .-, Framinq Insulation/Energy Drywall Ext./lnt. Lath Brown Coat N/asonry Pool Fence T-Bar Handicap Req Deputv Final Report Enqineer Final Report Flood Zone Certif ,,t, FINAL ?/ttht JhIZO Certificate of Occupancv //IV Notes, Remarks, Etc. Owner:_ @[ ?-tlz"q to crirninal pcnaltics)nd contracto r,K ?fe*^t r" ?--\-