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BUILDING. INSPECTOR RECORD tD/:itG.SITE.WORK DATE COMMENTS OWNER BUILDER DELCARATION I hcrcby aflirrn undcr pemlty of Frjury that I m cxcmpt fmm thc Contracton' Liccns Law for thc following rcNn (Sec.7031.5 Busincss aml Prcfcssion Codc): Any City or County which rcquircs o lrcmit to onstruct. alts. improve, dcmlish or rcpair any structurc. prior to its issurncc, also rcquircs thc applicant for such lrcmit to filc a sigrcd stalemnt lhsl hc or slE is liccnrcd pur$ant to thc prcvisions of lhe Contrctor'$ Licen$d llw (Chaptcr 9, Commcrcilg with Scction 7000 of Division 3 of thc Busircss 8nd Prcfcssions Codc) or that hc or she is cxcmpt ihcrcfrom and the basis for thc allcgcd cxcmption. Any violstion of SEtlln 703 1.5 by {ny applicant for a penrril subjcls thc applicant lo a civil pcnalty of not morc than fivc hundrcd dollars ($500). -1. as owncr of thc propcrty. or my cmployccs with wages as thcir liole comlrcnsation. will do thc work and thc structurc is not intcndcd or othrcd lor sale (Scc.7044. Busincss and Profcssions Codc: The Contractor's Licensc Law docs not apply to arr owncr of thc pnrpcrly who builds or improvcs thcrcon. and who dcrcs such work hirnsclf or hcrsclf or through his or hcr own cmployecs. provided lhat such improvcnrcnts arc not inlcndcd or olTcrcd tbr sah. lf. howcvcr, ttrc building or irnprovcrrnnt is sold within one )rcar of conrplction, thc Owncr Buildcr will have thc burden of proving that hc or shc did not build or improve thc pncpcrry for thc purglsc of salc). -1. as owncr of thc propcrty, am exclusivcly contracting with licenscd contraclors to construct thc projcct (Sec. 704/. Business and I'rofesskrn Codc: The Contractor's Liccnse Law docs not apply lo an owncr of proJrcrty who builds or improvcs thcrcon. and who contracts for such proicts with a Contractor(s) liccnsed pursuant to thc Contractor's Liccnsc [aw). -l amexcmpt undcr Section_. B. & P.C. lbr this reason. Date:JIwnnr. }VORKEILS' C()NI I'TNSAl'ION DECLARATI(TN I hcrcby aflirnr undcr pcnalty of Srcrjury onc of lhe f<rllowing dcclarations: -l huvc and will rnaintain a Ccrtiflcatc of Consent to Sclf-lnsurc for workers'compcnsalion. as providcd for byScction 37fi) of the latxrr Codc. for the pcrfbrnuncc of thc work for which thc pcrnrit is issucd. -l havc and will ntaintain workers' compcnsation insurancc. as rcquircd by Scction 37fi) of thc Labor Codc. lbr thc pcrformancc of -l ccrtify that in thc pcrforrrurnce of thc work for which this Jrcrmit is issucd. I shall not cmploy any Frcrson in any manncr so aslo bccomc subjcct to thc workcrs'compcnsation lawsof California, and agrcc that if I should bcconrc subjcct tothe workcrs' conrpensation provisions of Section 3700 of thc Latnr Code. I shall, forthwith cornply with thosc provisions. WARNING: Failurc lo sccure workcrs' compensation covcragc is unlawful. and shall subjcct an ernploycr to criminal pcnaltics and civil fines up to onc hundrcd thousand dollars ($100,000), in addition to thc cost of compcnsation. damagcs as providcd for the Scction 3076 of the Labor Codc, intcrcst and attorncy's fees. Dnre:7ho /lt k' -/- t I hcrcbyalllrrnundcr penaltyof pcrjury that I anr liccnscd undcr provision of Chuptcr 9 (commcncing with Scction 7000) of Division 3 of thc Business and Profcssions Codc. arxl my licensc is in full tbrcc and cft'e,ct. L-(o b7Liccrtsc I hcrcby affum undcr lrcnalty of perjury that thse is a snstructbn hnding agcrcy for thc prfomncc of thc work for whi,i this pcrmil is issucd (Ss. 3097, Civ. C.). kndcr's Namc: Lcndcr's Addrcss: APPI ICANT DECLARATION I hcrcby affinn under pcnalty of pcrjury one of thc following dcclarations: Denxrlition Pcrmits-Asbcstos Notificalion Fcdcral Rcgulations (Title 40, Part6) -Requircd [-et tcr of Notitication -l ccrtily that thc l'cderrl rcgulatiorts rcgarcling asbcstos rcrnovalarc not applicablc to this projcct. -l ccrtify lhat I havc rcad this application and statc that thc ahrvc intbrmalion is conect. I agrcc lo comply representatives of this City \ rroro. with all City and County and County to cntcr upon thcorclirranccs and State krws rclating to abovc nrcntioncd propcrty for /zrApplicant or Pennitce nanre construction, and hcreby authorizc 7/to Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/Ve nt/l ns u I atio n Roof Sheathinq Shear Wall Framinq lnsulatio nlEnerqy Drywall Ext./lnt. Lath Brown Coat Jtlasonrv Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif I / FINAL */n/2,Jrr$% Certificate of Occupancv I I Notes, Remarks, Etc. thc aml golicy numbcr are: Policy Number:_I h ev,