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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.CoMMF.NTS -OWNER BUILDER DEITARATION I hacbry affm unds poalty of pcrjury that I m qempt ftom thc Contre{ots' Liccrc Law for thc following resn (Se.7031.5 Buhes and Profsion Codc): Any City or Coumy which rcquire a pemit to constocl, alta. improvc. danolish or rcpair uy slrucluc, prior to its ismcq a&o rcquirc thc applic&t for such pcmh to filc 8 signcd stat@t thrt he or shc b licfiscd pwril to thc prcvisio$ of thc Contrrctor's Licenscd taw (Ctaptq 9. Comscing with Setion 7000 of Division 3 of thc Buitrs ed Prcfwions Codc) or thst hc or shc is cxmpt thqcfrom ud thc bosis for thc allclcd q@ption. Any violation of Setiotr 703 I .5 by my applimtforaparnitsubjctsthc applicmtroacivilpcoaltyofnotmorcthmlivchun&eddollm($500). _[. u omq ofthc prcpcrry. or my cmplo]B with wag6I thcL slc compasalion. wi[ do tlE wrk Ed tlE nrudrc b rct intqdcd or olFqrd for salc (Se.7044, Bcioe ud Profeiore Codc: Thc Contraclor's Licce llw do6 not spply to e om6 of thc lropqty who hrilds or imprcs thooq ed who doo swh w]t himsclf or hwlfor thrcugh his or h( om mplolcc, prcvidcd that such imfovmts rc not intodcd or ofrcrcd 6r sb. I[, how. tlE hrilding or inpromt is mU withh onc ]an ofconphtbrr the Owns Buildq will havc thc hrdar ofprcving thd hc or shc did oot buiH or improvc thc popqty br thc pupos of slc). -1, I omq of thc propqty, m ocluivcly contraaing with licqEcd contractoG to @nslIud thc projct (Se. 7044, BBin6 ud Profssion Co&: Thâ‚¬ Contrrctor's Liccnse Law do6 not apply to u ownq of propqty who builds or imprcvd thqon, md who contracls for such pojcds with a Contnao(s) licoscd pwwt to thc Contrac{or's Lic$e Liw). -l am excmpt B. & P.C. for this reason. I hcreby alfirm under penalty of perjury one of the following declarations: -l have and will maintain a Certificate of Consent to Self-lnsure for workers' compensation, as providd for by Section 3700 of the I-abor Code for the pcrformancc of the work for which thc po'mit is issued. _l have and will maintain workers' compensation insurance. as required by Section 3700 of the L^abor Code, for the performance of thc work for which this permit is issuod My workcrs' compensation insurance carrier and policy number are: ) Policv Number: Exoires: -l certi$ that in rhc pcrformance of the work for which this permit is issued. I shall not employ any person in any manner Iso as to become subject to the workers'compensation laws of California, and agree that if I should become subject to the worters' compersation provisions of Section 3700 of the Labor Code, I shall, forthwilh comply with those provisions. WARNTNC: Failure to secure workers' compensation coverage is unlawful. and shall subject an onployer to criminal ponlties and civil fines up to one hundred thousand dollars ($100,000).to the cost of compensation, damages as provided for the Scction 3076 of the labor Code. intercst and attorncy's ",r", oq fJl I J,l DECI.,ARATION I hereby affrm under penalty of pcrjury that I arn liccnsod under provision of Chapter 9 (commcncing with Section 7000) of Division 3 of the Business and Professions Code, and my liccnse is in full forcc and effect. Numbcr: Ilo t o. CONSTRUCTION LENDING AGENCY I hcreby affrm under peiralty of pcrjury that there is a construcrion k:nding agency for the pcrformance issued (Sec. 3097, Civ. C.). lrnder's Name: of the work for which this perrnit ls I-cndcr's Address: APPI ICANT DECL{IL{TION I hCIeby afErm under penalty of perjury one of the following declarations: Demolition Permits-Asbcstos Notification Fcderal Regulations (Tille 40. Part6) -Required lrtter of Notification -l ccrti& that the fedcral regulations rcgarding asbestos removal arc not applicable to this projcct.\ -l certi& that I have read this application and state that the above information is correct. I agree to comply with all City and County ordinances and State Laws relating to construction, and hereby authorize representatives of this City and County to enter upon the above mcntioned propcrty for Applicant or Agent Pernritee name purposes. Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/Ve nUl ns u latio n n Roof Sheathing TLtlu 'JrftoShear Wall tl /V Framing I lnsulation/Energy Drlnrvall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif I l\ F!NAL lalqlu Jtrtrao Certificate of Occupancy I l I V Notes, Remarks, Etc.I Contractor: -- r,r", ollzt lzl'-(&;n-