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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION I hercby affm und6 pflatty of pqjury thal I m cxcmpt ftom thc ContretoF' Licce law for the following rcen (56.70]1.5 Businss md Profession Codc): Any City or Coumy which rcquirs a pomit to @nstruct. altq, imprcve. danolish or repair uy structw, prior to ils isuace, also rcquirG the applicst for such pemit to filc a signcd statmmt thar hc or slrc b licoscd plNat to lhe Fovisio6 of thc Conrrctor's Liccnscd Law (Chapt6 9, Commencing with Sction 700O of Division 3 of thc Businc ud Prcfmioro Codc) or lhat he or shc is cxcmpt thqefrom ud thc basis for the allctscd qmption. Any violatiotr of S6tion 7031.5 by ili applicmtforapcmitsubjctsthe applicmttoacivilpcnaltyofnotmorcthmfivchundrcddollrs($500). --1. 6 owner of thc propcny, or my mplolc with wag6I their rcle compcmation, will do thc rc.k 4d thc stnrlrc is nol /\ intoded or offqcd for $le (Se.7044, Buins ed Prof*ioN Code: Thc Contractor's Liccre Law do6 not apply'- . - oMq ol -t thc propefly who buil& or improvc ttsot md who &s such wrk himsclf or heelf or through his or hc om a,rployc. provided that such inFovmts rc mt htadod or offqcd for sle. lf, how6q. thc building or imprc@t is oH within one )s. ofcompletio[ thc Owr6 Buiklq will havc the burda ofproving fta he or $c dll mt tuild or inprotc thc Fopqty for thc pt[porof mlc). -.1, as owner of the property. am exclusively contracting with licensed conlractors to construct the project (Sec. 7M4, Business and Profâ‚¬ssion Code: The Contractor's License Law docs not apply to an owner of property who builds or ilnprovcs thereon, and who conlracts for such projects with a Contracto(s) licensed pursuanl to the Contractor's License taw). -l am exempt undcr Section-. B. & P.C. for this reason. WORKER.S' COMPENSATION DECLARATTON I hereby affirm under penalty of pcrjury one of the follorving declarations: _l have and will maintain a Certificate of Consent to Self-lnsure for workcrs' compersation. as provided for by Section 3700 of thc Labor Code, for the performance of the work for which the perrnit is issued. _l have and will rnaintain workers' compensation insurance. as required by Section 3700 of the Labor Code. for the perfonnance of lhe rvork for which this permit is issued. My workers' compensation insurance carrier and policy numkr are: Policy Number: Expires: -l certi& that in the performance of the work for which this permit is issued, I shall not employ any pcrson in any manner so as to become subject to the work6s'compensation laws of California and agroe that if I should become subject to the worketrs' compensation provisions of Section 3700 of the Labor Code, I shall. forthwith comply with those provisions. WARNING: Failure to sâ‚¬cure workers' compâ‚¬rsation coverage is unlawful. and shall subject an employer to criminal panalties and civil frnes up to one hundred thousand dollars ($100.000), in addition to the cost of compensation, damages as provided for thc Section 3076 of the Labor Code, interest and attorney's fees. A nnlinonl. LICENSED CONTRACTOR DECT.,ARATTON I hereby affrm under penalty of pcrjury that I am licensed under provision of Chapto 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 Nurnber: W I hrcby affnn undo Fnalty of pqjury that thrc is I coNtructiotr leding ag6cy for the pqfomcc of thc wort for which this po'mit b issucd (Se. 3097, Civ. C.). Lendcr's Name: lcnder's Ad&ess: APPLICANT DECLARATION I herdry afiinn under penalty of perjury one of the following declarations: Demolition Permits-Asbestos Notification Federal Regulations (Title 40. Part6) -Required Letter of Notification -l cqti& thar thc fedoal rcgulariom rcguding cbatos rmoval sc not applicsble to ihis prcjrt. -f cdiry that I havc red this application sd statc thd thc above infomation is conc1 I agrc to comply with all City md County ordimcG md Statc law rclatiry io building consruaion and hreby authorir rcFMtariv6 of this City ad Coutyto otq upotr thc above motioncd prcpcny for iroparion purpos. Applicent or Agent Slgneture: Date:_ Pcrmitee name (print): Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/Ve nUl n s u latio n Roof Sheathinq q- Z-? t D'46ff V, Shear Wal! Framing lnsu lation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif FINAL Q-?-zt b-ftl- Certificate of Occu pancy Notes, Remarks, Etc. Dete: Contractor:-