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BUILDING. INSPECTOR RECORD t SITE.WORK DATE ID/SIG COMMENTS OWNER BUILDER DEI.CARATION I h6c$, aflim undq poalty of perjury that I m cxcmpt ftom thc Contractoc' Liccre liw for thc following r@n (Ss.7031.5 Buincs od Prcfsion Code): Any City or County which require a pamh to coNtruct. altq, improvc, dmolish or rcpair ay struc1uc, prior to its iswcc, also requirs lhc applicilt for such psrnit to filc a signed sldm@t that hc or slrc b licoucd pwut to thc prcvisions of thc ContBctor's Licmsed taw (Chaptq 9, Comcncing with Sstiotr 7000 of Division 3 of thc Bsins ild Prcfe$ioru Code) or that hc or shc is ermpt th@from sd thc b&sis for the allegcd amption. Any violation of Sâ‚¬1bn 703d.5 by oy applicant for a psmit subjcts thc spplicet to I civil pmlty of not more tha five hun&cd dollus ($500). _1. as o\tmcr of the properly, or my employees with wages as their sole compensation, will do the work and the strucrr. b ; intended or offered for sale (Sec.7044, Business and Professions Code: The Contractor's License Law does not apply to an orller of the property who builds or itnprovcs thereon. and who does such work himself or herself or through his or her own cmployecs. provided that such improvcrnents are not intendcd or offered for sale. lf. howwer. the building or improvernent is sold within one ye:r of complaioq the Or,vner Builder will have the h,rden of proving tha he or she did not build or improve the propoty for the purpose Df sale). _1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044. Btsiness and Profession Code: The Contractor's License Law does not apply to an owner of propcrty who builds or improves thereon. and rvho contracts for such projeos with a Contracto(s) licorsed pursuant to the Contractor's License taw). { -l am exempt under Section-. B. & P.C. for this reason. Date: WO RKER,S' COMPENSATIO N DECLARATION I hereby affirm undcr penalty of perjury onc of the following dcclarations: _l have and will maintain a Ce'ntificate of Consent to Self-lnsure for work6s' compcrsation, as providd for by Section 3700 of the Labor Code, for the perfonnance of the work for which the pennit is issued. _l have and will maintain workers' compcnsation insurance. &s required by Section 3700 of the Labor Codc, for the pcrformance of the work for which this permil is issued. My workers' compensation insurance carier and policy number are: Policy (*rfthat in the perforrnance of thc work for which this permit is issued. I shall not onploy any person in any manner e so .ls to becorne subject rvorkers' compensation WARNING: Failurc to to the workâ‚¬rs'cornpcnsation laws of California. and provisions of Section 3700 of the Labor Code, I shall, that if I should become subject to the cornply with those provisions. secure workers'compensation coverage dollars ($100.000), in , is unlawful.shall subject an onploycr to criminal pcnalties and civil fines up to one hundred thousand addition to cost of compensation. damages as provided fo1$e Section 3076 of the Labor Code. interest and fees. Dutc:E/? t /al I hereby affirm under penalty of perjury that I am licensod 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full ( -l,o /oittlb CONSTRUCTION LENDTNG ACENCY I hreby affm unda penalty of pcrjury that thqe is a connrudion lcnding sgocy for thc pqfomcc of thc mrk for which this pqmit b issued (Sc. 3097, Civ. C.). Lcnder's Name: Lcnder's Address: APPLICANT DECLARATION I hereby affinn under penalty of perjury one of the follorving declarations: Demolition Permits-Asbestos Notification Federal Rcgulations (Title 40. Pan6) __Required [.etter of Notification _l certi& that the federal regulatlUns regarding removalare not applicable to this project. above information is correct. I agrcc to comply a _l certi$ that I have read this application and state the with all City ard c.:Unty and County to enter upon the t ordinances and State Laws rclating to building and hereby authorize representatives of this City above mentioned property for Applicant or Agent { / "l Pcrmitee name q. \ Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloor/VenUl nsu Iation Roof Sheathing Shear Wall Framinq lnsulation/Energy Drnrvall Ext./lnt. Lath Brown Coat lvlasonry Pool Fence T-Bar Handicap Req. Deputy Final Report Enqineer Final Report Flood Zone Certif /.A Sou4rL ,4T{4c. l{ ng{T cl /ts/ zt Z;t-t(3'U FINAL /D-*2 t ErrSGfL Certificate of Occupancy Notes, Remarks, Etc. Carrier: o*", /f /z)rlt