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INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNFR BTII LDTR NELCARATION I hereby affrrm under penalty of perjury that I am exanpt form the Contractors' l.iccnse l-aw for the following reason (Sec.70-11 .5 Business and Profession Code): Any City or County which requires a permit to corlstruct. alter. improve. demolish or repair any structure. prior to its issuance. also rcquires the applicant for such permit to file a signed statement that hc or she is licensed pursuant to the provisions of the Contractor's l.icensed Larv (Chapter 9. ('omrnencing rvith Section 7000 of Division 3 of the Business and Professions Code) or that he or she is exenpt therefrom and the basis for the alleged exemption Any violation of Section 703 L5 by any applicant for a pcrmit subiects the applicant to a civil penalty of not more than fir'e hundred dollars ($500). Y t. .^. o\r,ner of the property. or my employees rvith rvages as their sole compensation. u,ill do lhe wort and the structure is not intended or offered for sale (Sec.7044. Business and Professions Code: The Contraclor's License [-aw does not apply to an owncr of the property rvho builds or improves thereon. and u'ho does strch u'ort himself or herself or through his or her own employees. provided that such improvements arc not intended or offered for sale. lf. hou'erro. the building or imp,rovement is sold within one year of cornplaion. the Owner Builder will have the hurden of proving that he or she did not build cn improve the properW for the purpose of sale). N_o l. a. o\\'ner of the property. am exclusively contracting with licensed contractors to construcl the p,roject (Sec. 7M4. Business and Profession ('ode: The ('ontractor's License l-aw does not apply to an owner of property who builds or improves thereon. and rvho contracts for such pn{ects with a Contracto(s) licensed pursuanl to the Conmclor's Liccnse Larv). !o-l ,,n exempt under Section -. B. & P.C. for this reason. Iv!'ORKTRS' ('OM PFNSATION DFCI A RATION I hereby affrrm under yrcnalty of perjury one of the following declarations: No-l h.". ancl rvill maintain a ('ertificare of Consent to Self-tnsure for rvorkers' compensation. as provided for by Section 3700 of the l.abor Code. for the performance of the work for which the Frcrmit is issued. YES I have and rvill rnaintain workers' compensation insurance. as requited by Seclion .1700 of the labor Code. for the performance of the rvork for rvhich this permit is issued. My rvorkers' compensation insurance carrier and policy number are: Security National( arl rcl': swc1307380['olict Ntutrhcr: 1112312021 l;r pires: NO I cerrifo that in the performance of the work for which this permit is issued. I shall nol cmploy any person in any manner so as to become sub.iect to the workem'compensation laws of California. and agree that if I should become subiect to the worters' compensation provisions of Section 3700 of the l,abor Code. I shall. forthwith comply with those provisions.. W'ARNING: Failure to sea'ure worters'cornpensation coverage is unlawfrrl. and shall sub.iect an employer to criminal penalties and civil fines up to one hundred thousand dollars ($100.000). in addition to the cost of compensation. damages as provided for the Section 3076 of the l-abor ('ode. interest and attomev's fecs. LICENSFN ('ONTRACTOR NF'('I ARATION I hereby alTinn under penalty of periury that I arn licensed under provision of Chapter g (commencing rvith Section 7000) of Division 3 of the Business and Professions Code. and my license is in ftrll f<rrce and effect. c2(}'c30 License ('lass:78/t495 l.icense Number (:ONSTRTICTION I FNDING {,(ITNCY I hereby affirrn under penalty of perjury that there is a construction lending agency for the perfonnance of the rvork for which this pennit is issued (Sec. .1097. Cir'. C.). l.ender's Name: l.ender's Address: APP] I('ANT NTCI ^RATION I herebnr, aftinrr under penaltv of perlurv one of the followrng declarations [)enrolrtion Penrrrts-Asbestos Notrficalron Federal Regulatrons (Trtle 40, Part6) No Required I-etterof Notification t1t t cerlify rhar the federal regulations regarding asbestos removal are not applicable to this pro.iect. YEs I certi$, that I have read this application and state that the ahove infonnation is con'ecl. I agree to comply u'ith all City and Courty ordinances and State l.au's relating to building constntction. and hereby authorize representatives of this City and County to enter upon the atnve mentioned property for inspection purposes. Reroof Roof (Diaphragm Sheathing/Frame) Structural Final Plumbing Under Floor I Under Slab Rough Shower Pan / Tub Test Water Service Sewer / Sewer Cap Gas Air Pressure Test Plumbing Final Electrical Service (Meter I Panel) Grounding / Bonding Rough Electrical Final Mechanical Gas Air Pressure Test Rough Piping (HW, CW, etc.) Exhaust Ducts t [/echanical Final <{l n Lzt {Natt\J Notes, Remarks, Etc. I