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BU!LDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG COMMENTS OWNEN BUILDER DELCARATION I hcrcby affrm undcr pcnahy of Frjury tlEt I m crcr{rt frcm thc ContEctoE' Liccns lnw for tlrc fotlowing Men (Ss.7031.5 Busincss rrxl Prcfcssion Codc): Any City or County which requircs a trcmil to qinstruct, altcr, imprcvc, demlish or rctEir my stNcturo, pri)r to iIs issumc, also rcquircs thc a0plicant for such Frmit lo file a signcd strtcmnt thst he or slE Ls liccnsd pusuut to thc lrcvisions of lhc Contnctor's Liccn$d lrw (Chapter 9, Comrcing with Sclion 70m of Division 3 of the Busiress md PmfcssionsCodc)orth.thcorshciscxcmptthcrcfromsrdtheb6sisforthcallcgcdcxcmption. AnyviolationofSeclionT03l.5byany applicmt for o lrcmit subiEts thc rpplicant to s civil pcmlty of not mrc thm fivc hundrcd dolles ($500). _1. as owncr of thc Fnopcrty, or my cmployces with wagcs as their sole comlrnsation, will do thc work and the stnrcture is not intcndcd or ofl'crcd for sulc (Sec.7M4, Busincss and Prolbssions Code: Thc Contraclor's License law docs not apply to an owncr of the pnlJrcrty who builds or improvcs thcreon, and who docs such work hirnself or hersclf or through his or hcr own employecs. providcd that such improvcrncnl.s arc not intendcd oroflbrcd for salc. lf, howcrtr. thc building or in{rrovenrnt is sold wilhin one }rcar of complction, lhc Owner Builder will have thc burdcn of proving that hc or shc did not build or improve thc property for the purynsc of sab). -1, as owncr of thc propcrty, am cxclusivcly contracting with liccnscd conlractors to construcl thc projcct (Sec. 7(}14, Busincss and ltofession Code: Thc Contractor's Liccnse Law docs not apply to an owner of propcrty who builds or improvcs lhercon. and who contracts for such projccts with a C-ontracto(s) liccnsed pursuant to thc Contractor's Licensc [:w). _l arn cxcnlpt undcr Scction_. B. &for this rcason. ,",", Y lt^/u I hcreby affirm undcr pcnalty of pcrjury one of thc following de.clarations: _l havc and will maintain a Certificatc of Conscnt to Self-lnsure for workcrs'compcnsation. as povidcd for by Scction 3700 of thc l.abor Code. for thc performance of thc work for which the permit ls issucrl. _l havc and will rnaintain workers' compensation insurance, as required by Scction 3700 of thc Labor Code, for thc performance of the work for which this Jrcrrnit is issuod. My workcrs' compensation insurancc carrier ard plicy number arc: 4., Policy _l cerrify that in thc pcrformancc of thc work for which this permit is issued. I shall not enploy any pcrson in any rnnncr so as lo bcconrc subjcct to thc workcrs' comlrcnsation laws of California. and agrce that if I should beconrc subject to the workers' conqrcnsation provisions of Section 3700 of thc labor Code, I shall. forthwith comply with thosc provisions. WARNING: Failure to sccurc workcrs' cornpcnsation coveragc is unlawful. and shall subjcct an employer to criminal pcnalties and 1 civil lirrcs up to onc hundrcd thousarrd Scctiorr 3076 of thc Latxrr Code. irrlcrcst Dare: rl /ulh; dollars ($100.000), in and attorncy's fees. to thc cosl o[compcnsation. darnages as providcd for thc t It I hcrcby allirrn undcr pnalty of pcrjury that I arn licenscd Chapter 9 (comnrncing with Scction 7000) of Division 3 of the Busincss and Profcssions Code, and my license is in full force ard effcrt. Liccnsc Class: Liccnse Numbcr: l)atc. W I hcrcby atlirm under ;rcn8lty of pcrjury thar thrc is a onsiructhn hnding agercy for the pedormcc of the work for which this pcrmit is issed (Src.3097, Civ. C.). [:ndcr's Nam. l.endcr's Addrcss: APPLICANT NT'CLARA TION I hcreby aflirm under pnalty of pcrjury one of thc following declarations: Dcmolition Pernrits-Asbestos Notificalion Fedcral Regulations (Titlc 40. Part6) _Required l.cttcr of Notifrcation _l ccrtify that thc fcdcral rcgulations rcgarding asbcslos rcnxrvalarc nol applicahlc to this projcct. -l ccnify that I h.vc rcad Ihis applic.tion and statc thil thc abovc informlion is conct. I agre to omply wilh all Cilyand County ordinanccs and Strlc laws rclaling to building constrctiotr and hcrcby aulhorizc rcp]csnlatires of lhis Cily and Counly to stcr ulbn thc abovc nrcntioncd propcrty for Applicant or Agertl I'erntilee nanre ptq)oscs. I Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenVl nsu latio n Roof Sheathinq Shear Wall Framinq lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req. Deputy Final Report Enqineer Final Report Flood Zone Certif A /^ F!NAL t-Ztr-V \JrlD,{ Certificate of Occu Notes, Remarks, Etc. Rev. 08-07-201 5 Applicant: o,,", llLt fzt o