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BUILDING- INSPECTOR RECORD SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATTON I hcrcby afTirm undcr lEnally of pcrjury that I m cxctrrpt frcm thc Contraclon' Lkcnsc ljw for thc following rcamn (Se.7031.5 Busincss lrd Profcssion Codc): Any City or County which rcquircs I lEmit to snstruct. ahcl improre. demlish or rcpair any strucnrrc, prior to its issumc, ds rcquircs thc applicmt for such IErmit to lilc a signcd stalcrcnl thtrt hc or dre is licens4 pursmt lo Ihe prcvisions of the Contraclor's Liccn*d taw (Chaptcr 9. Comrencing wilh Sstion 7000 of Division 3 of thc Busircss ud PrcfcssionsCodc)orthathcorshciscxcnrptthcrcfrcmandthebrsisforthcallegcdcxcmption. Anyviolationofs$tionT03l,5byany applicont for a lErmit subjccts lhc applicanl to a civil pcnally of nol mrc than five hundrcd dollars (3500). _1, as owncr of thc propcrty. or my cmployecs with wagcs as thcir solc conqrcnsation. will do thc work and thc structurc Ls not intcndcd or ot'fcrcd for salc (Sc-c.7044, Busincss and Profcssions Codc: 'I'he Contractor's Liccnsc Law docs not apply lo an owncr of thc proprty who builds or improves thcrcon, arxl who docs such work hinrsclf or hersclf or through his or hcr own employccs. providcd that such irnprovenrcnts arc not intcndcd or otTcrcd tbr sah. lf, howcvcr. thc building or improverrcnt is sold within one ycar of cornplction, thc Owner Buildcr will havc thc burden of proving that hc or shc did not build or irrprovc the proprty for the purJnsc of salc). _1. as owncr of thc propcrty. am cxclusivcly contracting with liccnsed contractors lo construct thc projcct (Scc. 7U4, Busincss and hrofcssion Codc: Thc Contractor's Licensc Law does not apply lo an owncr of progrcrty who builds or improves lhercon, and who contracls for such projccts with a Contractor(s) liccnscd pursuant to thc Contractor's Liccnsc t aw). _l anr cxcmpt undcr Scction_, B. & P.C. for this rcason. WORKERS' COMPENSATTON DECI ^ RATION I hcrcby affirm undcr penalty of perjury onc of the following declarations: _l havc and will maintain a Ccrtificatc of Conscnt to Self-lnsurc for workcrs' conrpensation. as provided for by Scction 3700 of thc for thc grcrformancc of thc work for which thc pcrmit ls issucd. will rnaintain workcrs'3700 of thc l^abor Code, tbr the pcrformancc of this pcrnrit i.s and policy nurnbcr arc: I I t Policy -l ccrtify lhat in thc pcrlbrnmnce of thc work for which this is issucd. I shall not cmploy any pcrson in any manncr so as to bccome subjcct to thc workcrs'compensation laws of and agrcc that if I should bcconrc subjcct to thc workcrs' cotnpcnsation provisions of Scction 3700 of thc Labor I shall. forthwith conrply with thosc provisions. WARNING: Failure to sccurc workcrs' conrpcnsation unlawful. and shall civil Iincs ul)thousarrd dollars to lhc damagcs as providcd for thc Fintcrcst and I hcrcby affirrn undcr penalty of pcrjury that I arn 9 7m0) of Division 3 of thc Busincss and Professions Code, and my in tull lirrcc iud ct't'cct. 7q W I hcrcby affirm undcr pcndty of pcrjury that thcrc is a construction hnding agcncy for thc Fsforroncc of thc work for which this Frmil is issucd (Se. 3097, Civ. C.). [rrtder's Nanrc: APPI ICANT DECT ARATION I hcrcby affirm undcr pcnalty of perjury onc of thc following declarations: Dcrnolition Pcrrnits-Asbcslos Notification Fcdcral Rcgulations (Titlc 40. Part6) _Rcquircd lrttcr of Notification rcnxrvalarc not applicable to lhis project. I agrcc to City County representativcs of this/ Applicant rlr Agenl I'crrrritcc nanre thc atnvc with ? upon thc Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenVl n su I atio n Roof Sheathing Shear Wall Framing lnsu lation/Enerqy Drywall Ext./lnt. Lath Brown Coat lt/asonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif FINAL Certificate of Occupancv Notes, Remarks, Etc. to criminal penaltics and Date: [,cndcr's Addrcss: ( rrrilrl l: ' and