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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS )i toeuy amm unda pmtty orperj- *" ,olLT."pukl",['.tfl"Hto,lr* ,* ror the roltowins r"*n 1sc.zo!t.s Buines and Profsion Code): Any City or County which require a po'mit to @ciruct, alto, improve dmolish or rcpair uy structuc, prior to its isuocc. also rcquirc rhc applicmt for such pqmit to file a signcd statmmt that hâ‚¬ or $c b licqEcd pledt to the provisiore of the Contrrctor's Licqscd Law (Chapt6 9. Comcncing with Setion 7000 of Division 3 of thc Busins ud Prcfssions Code) or that hc or shâ‚¬ is exâ‚¬mpt thqefrom ild thc basis for thc allcgcd umpion. Any violation of Salion 7031.5 by ey applicut for a pcrmit subjets thc applicant to a civil pcnalty ofnot morc tha five hundrcd dollus ($500). -1. as owner of the propeny, or my employees with wages as their sole compensation, willdo the work and thc struclure is not intended or offerd for sale (Sc.7044. Business and hofessions Code: The Contraclor's License [-aw does not apply to an owner of the propei'ty who builds or improves thereon. and who does such work himself or herself or through his or hcr own cmployees. provided that such improvonents are not intendod or offâ‚¬rod for sale. lf, howcrrer, the building or improvement is sold wilhin one year of cornpletion. the Orvner Builder will have the hrden of proving that he or she did not build or improve the propoly for the purpose of sale). _1. as owner of the propeny, am exclusively contracting with licensed contractors to construct the project (Sec. 7U4, Business and Profcssion Codc: The Contractor's Licensc Law does not apply to an owner of property who builds or improves thereon. and who contracts for such projects with a Contracto(s) licensed pursuant to the Contractor's License taw). _l am exempt under Section_. B.P.C. for this rcason. o*u, {/4 * J:( owner: ,, I hcreby affrrm under pcnalty of po'jury one of the following .-l havc and will maintain a Ccrtificate of Consent to Self-lnsure for workers' compersation, as provided for by Section 3700 of the l-abor Code, for the performance of the work for which the pennit is issued. -l have and will maintain workers' compensation insurance, as rcquired by Section 3700 of the labor Code. for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Carrier' Policy Number: Expires: -l certify that in the performance of the work for which this p,ermit is issued, I shall not employ any person in any manner so as to become subject to the workers'compensation laws of California. and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall. forthwith comply with those provisions. WARNING: Failure to serure workers'compensation coverage is unlawful. and shall subject an onployer to criminal poralties and civil fines up to one hundred thousand dollars ($100.000). in addition to the cost of compensation. damages as provided for the I Section 3076 of thc Labor Code, intercst and attorney's fecs. 2 DECI.,ARATION I hereby affrnn under penalty of perjury that I am licensed under provision of Chapter of the Business and Professions Code. and my license is in full force and effect. 9 (comrnencing with Section 7000) of Division 3 License Number: flq t r.. CONSTRUCTION LENDING AGENCY I hrcby affm uda pcnalty of pcrjury tha! thft is a ooslruc{ion kading agocy for thc pafomcc of thc rcrt for which this psmil b issucd (Se. 3097, Civ. C.). lmdd's Nmc: Lender's Address: APPLICANT DECLARA'TION I herdry affinn under penalty of perjury one of the following declarations: Dernolition Pennits-Asbestos Notification Federal Regulations (Title 40, Part6) _Required Letter of Notification -l cotiry thal thc fcdml rcgulatioro rcguding rbalos rooval rc not applicablâ‚¬ to this projcct. _l cstiry thal I havc rod this application and state thar thc abovc infomtion is coret. I agc to comply witt 8ll City ild County ordimncG ud Statc las relating to building constructio& ad h6eby authorizc r@r6ataiv6 of this City md Couty to mtq upon thc above mentioned property for inspeoion Applicant or Agent l)erntittre nilnre Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloor/VenUI nsu Iation Roof Sheathing Shear Wall Framing lnsulation/Energy Drnruall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif t//t FINAL to/</t Certificate of Notes, Remarks, Etc.a o U r I -icense Contractor: oarc,t/^23-2/ a