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BUILDING- INSPECTOR RECORD SITE-WORK DATE ID/SIG COMMENTS OWNERDUILDERDELCARATION , . I hcrcby affirm under IEMlty of pcrJury that I m cxcmpt frcm thc Contncton' Licens llw for thc following rearcn (54.7031.5 Busincss and Profcssion Codc): Any City or County which rcquircs a 1rcrmit lo construct, altcr. improvc, dcmlish or rcpir any structurc. prior to its issuancc, trlw rcquircs thc applicut for such Frmit to filc a sigrcd statemnt lhat hc or slE is liccnscd puEuant to thc pmvi$ions of thc Conlrrctor's Licensd [:w (Choptcr 9, Comrcncing wilh Sction 7fi)0 of Division 3 of thc Business and Prefcssions Codc) or lhat hc or shc is cxcmpt thcrcfrom and thc besis for lhe lllcgcd cxcmption. Any violation of SNtion 703 1.5 by any applicant for B 1rcmit subjccts thc applicant to a civil pcnalty of not mrc than fivc hundrcd dollus (S500). _1. as owncr of the oropcrty. or my employecs with wagcs as their solc compcnsation, will do the work and thc structurc is not intendcd or offcrcd for sale (Sec.7044, Business and hofcssions Code: The Contraclor's License [:w docs not apply to an owncr of thc proJrcrty who builds or improvcs thencon, and who docs such work himsclf or hcrsclf or through his or her own employccs, providcd that such improvenrcnts arc not intcndcd or offcrcd for salc. lf, howevcr, thc building or improvcrrcnt is sold within onc ycar of comphtion. thc Owncr Builder will have the burdcn of proving that he or shc did not build or improvc the pmpeny for the purpsc of salc). -1. as owncr of the propcrty. am cxclusively contracting with liccnscd contractors to construcl thc projcct (Scc. 7W. Busincss and Profession Code: The Contraclor's License Law does not apply lo an owncr of property who builds or improves thereon. and who contracls for such projects with a Contractor(s) liccnscd pursuant lo thc Contractor's Licensc L:w). -Ialncxc!nptundcrSection-.B.&P.C.forthisrcason.I)nte: }VORK F' RS' COI\I PENSA'I'ION DECLARATION I hcreby affirnr under pcnalty of pcrjury one of thc following declaralions: _lhavcandwill maintainaCcrtificatcofConsenttoSclf-hrsurcforworkcrs'conrpensation,as providcdforbySection3T00ofthc Labor Codc, l'or thc perfornuncc of thc work for which thc pcrrnit is issucd. _l havc and will maintain workcrs'compensation 3700 of thc tabor Code, for thc ;rcrf<lrmancc of thc work tirr which this pcrmit is issucd. My and plicy numbcr arc: a 4,4t Policy --Lo ,1- _l ccrtify that in the pcrfornrancc of thc work for which this pcrmit is issucd. I shall not employ any lrcrson in any manncr so as to bccomc subjcct to thc workcrs' compensation laws of California. and agrcc that if I should bccomc fuUpct to thc workers' comlrcnsation provisions of Scction 3700 of thc [:tnr Code. I shall. fbrthwilh comply with thcrsc provisions. WARNING: Failure to sccure workcrs' civil lirrcs up lo one hundrcd thousand Scction 3076 of the labor Codc. intcrcst and lhc .L I hcrcby affirm undcr pcnalty of pcrjury that I am liccnscd undcr provision of Chaptcr 9 (commencing with Scction 7000) of Division 3 of thc Busincss and Profcssions Code. and my liccnsc is in full force Bnd cffcct. Liccnsc Nurnbcr: I hcrcby alllrrn undcr pcnalty of pcrjury that therc issucd (Scc. 3097, Civ. C.). a construction lcnding agcncy for thc grcrfornrancc of thc work for which this permit is lrnder's Namc: [-cndcr's Addrcss: APPLICANT DECLARATION I hcrcby all-nnr undcr pcnalty of pcrjury one of thc following declarations: Dcrnolition Pcrmits-Asbcstos Notification Federal Rcgulations (Titlc 40, Paa6) _Rccluircd [rttcr of Notification _l ccrtify lhat thc fedcral rcgulations rcgarding asbcstos removal arc not applicablc to this projcct. _l ccrtily that I have read this application and state that thc atnvc infornution is corrcct. I agrcc to conrply with all City and County ordinanccs and State Laws rclating to building construction, and hcrcby authorizc of this City and County to cnler upon thc abovc nlcnlioncd propcrty lbr Applicant or Agent Permitee nanre o,,",'*-17-Ll Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/Vent/l nsu I atio n Roof Sheathinq J uAz- Shear Wall /l V \J Framing lnsu lation/Enerqy Drywal! Ext./lnt. Lath Brown Coat N/asonrv Pool Fence T-Bar Handicap Req. Deputy Final Report Enqineer Final Report Flood Zone Certif. I FINAL 1 t lt t )-,N o\ Certificate of Occupancy ll t U Notes, Remarks, Etc. Owner:_ \ --.L6- an to crinrirrul Date:_b^ / 7-L/A a