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BU!LD!NG. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DEI,CARATION I h6eby affirm unds pâ‚¬nalty of perjury thd I m qmpt fiom thc Contractos' Licw l:w for thc folb*ing .*n lio.ZOlt.S Businss ud Profeion Codc): Any City or County which rcquirc a ponit to @nstruct, altq, improvc, dmrolish or rcpeir uy struciue. prior to its isswcc. also rcquire thc applicet for such pannil to filc a signcd stdmmt that hc or slrc b licmscd plNdt to the prcvisions of thc Contretor's Licenscd Law (Chaptq 9. Commcncing with Setion 7000 of Division 3 of thc Buincs md Prcfessions Code) or thal hc or shc is excmpt thGcfrom ed the bssis for the allcgcd exmption. Any violation of Sa-tion 703 1.5 by any applicantforapcmitsubjetsthc applicanttoacivilpenaltyofnotmorcthufivchundreddollus($500). -1. as owner of the property. or my employccs with wages as their sole cornpensation. willdo the work and the structure is not rntended or offered for sale (Sec.7044, Business and hofessions Code: The Contractor's License Law does not apply to an owner of thc propctty who builds or improves thereon. and who does such wort hirnself or herself or through his or her own employees. provided that such improvonents arc not intcndod or offirod for sale. I[, hower/er. the building or imp,rovement is sold within one ]eu of complaion. the Orvner Builder will have the hrden of proving tlra he or she did not build or impove the propoty for the prx?ose of sale). -1. as owner of the property, am exclusively contracting with licenscd contractors to construcl thc p,roject (Sec. 7044, Business and hofession Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon. and who contracts for such projects with a Contracto(s) licensed pursuant to the Contractor's License Law). -l arn exempt under Section-, B. & P.C. for this reason. I)nto'0*-or' WORKERS' COIITPENSA DECLARATTON onc of the following declarations:I hereby affrrm under penalty of pojury -l have and will maintain a Certificate of Consent to Self-lnsure for workers' compensation, â‚¬rs provided for by Section 3700 of the Labor Code. for the performance of the work for which the permit is issued. _l have and will maintain workers' compensation insurance. as required by Section 3700 of the L,abor Code. for the pcrformancc of the work for which this permit is issued. My workers' compcnsation insurance carier and policy number are: Carrier: Policv Numbcr: Expires: -l cediry that in thc perfororc of thc work for which this pqmit is issued. I shall not onploy any pomn in uy mancr rc a to beomc subjet to the rcrk6'compcEarion law of Califomia, ild !8rc that if I should beome subjet to the workm' comperution prcvisiou of Sction 3700 of thc labor Code I shall. forthwith comply with thos prcvisiom. WARNTNC: failuc to sre rcrkm' cotnpqEalion covmgc is unlawful, ad shall subjct m mpb)rcr to qininal poEllics ud civil fine up to onc hundrcd thousd doll6 ($100.000). in addition to thc cost of compcwtion. dmag6 s providcd for thc SEtion 3076 of the tibor Code, intsGt od attomcy's fe. LICENSED CONTRACTOR DECT,ARATION I hereby a(Tirm under penalty of petjury that I arn licensed under provision of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code. and my license is in full force and effect. License Class: License Numbcr: Contrector: CONSTRUCTTON LENDING AGENCY I hwby affirm undq pemlty of pcdury that thae is a comtruction loding agency for the pcfommce of the work for which this pqmil is issued (Ss. 3097. Civ. C.). Lender's Narne: Lender's Ad&css: APPLICANT DECLARATION I herdry aflirm under penalty of pojury one of the following declarations: Demolition Permits-Asbestos Notification Federal Regulations (Title 40. Part6) _Required Letter of Notification -l cdiry thal thc ftdral rcxulatiom rcgarding rbstos movd uc not applicablc to this projct. _l cetiry th8t I havc ud this applicarion dd statc that thc abovc informdion is corâ‚¬t. I agre to mmply with all City ud County ordimcG ud Statc ks clatiDg to building consructiorl ed hftby authorizc rcpreatativc of this City ad Couty to ata upon thc .bovc m@tionod prcpqty for iospcrion purpos. Appliont or Agsa Slgnrturc: Drlc:_ PemltE trtme (prlnt): Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloor/Ve nUl n s u latio n I .A I Roof Sheathins aftlzt Lurc7 )ffl Noâ‚¬ Shear Wall , Framinq !nsu !ation/Energy Drywall Ext./lnt. Lath Brown Coat Jtlasonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif lt 7 FINAL Tntn Lu (91) Certificate of Occupancy t ,\.7 Notes, Remarks, Etc. \ Na E_o ON 3' bortiNâ‚¬)S cAfP. ok -tD co\76tu m \--z Date:_