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T BI.TTLDING- INSPECTOR RECORD SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcrcby affirm undcr pcnalty of pcrjury that I du exempt frcm thc Contracton' Liccns hw for rhe following rcarcn (Scc.70315 Busincss and Profcssion Codc): Any City or Counly which requircs a frcrmit to onslruct, alts, improvc, demlish or rc;nir any strudurc, prior to its issuancc, dm rcquircs lhc applicant for such lrcrmit to fih a signcd statcrcnt that he or she is liccnsd pusant to thc prcvisions of thc Contractor's Licenscd I:w (Chaptcr 9, Comrcncing with Sction 7000 of Division 3 of the Busincss lnd PrcfessionsCodc)orthathcorshckcxcmptthcrefromandthcbasisforthcallcgcdcxcmption. AnyviolationofSctionT03l.5byay appliclnl for a 1rcrmit subjcts thc applicanl to a civil penahy of not mrc Ihan fivc hundred dolhs (5500). -1. as owncr of thc propcrty. or my employecs with wages as their solc compcnsation. willdo thc work and lhc structurc ls nol intendcd or offcrcd lbr salc (Sc.c.704+. Business and Professions Code: Thc Contractor's Licensc [:w docs not apply to an owncr of thc property who builds or improvcs thcreon, and who clcrcs such work himsclf or hcrself or through his or hcr own employecs, providcd that such improvcnrcnts arc not intcndcd or <lfTercd lbr salc. lf. howcvcr. the building or improvcnrcnt is sold within onc ycar of conpletion, thc Owncr Buildcr will have the burdcn of proving that he or shc did not build or improve the propcrty for the purpse of salc). -1. as owncr of thc propcrty, am exclusivcly contracting with liccnscd contractors to construct thc projccl (Scc. 7W, Busincss and Ptofession Codc: The Contractor's Licensc Law docs not apply lo an owner of proJrcrty who builds or improvcs thercon. and who contracts for such projects with a Contractor(s) licenscd pursuant to thc Contractor's Liccnsc kw). -l am cxcmpt under Section_. B. & P.C. for this reason. Date:Owner:_w(lRI(r'w DECLARATION I hcreby affirrn undcr pcnalty of perjury onc of the following dcclaralions: -l havc ard will maintain a Certificate of Conscnt to Self-lnsure for workcrs' compcnsation. as provided for by Scction 3700 of the Labor Codc, for lhc pcrfornrancc of thc work for which thc pcrmit ls issucd. LI have and will maintain workers' compensation insurancc. as rcquircd by Section 3700 of the l-abor Codc, for thc pcrformancc of thc work for which this permit is issucd. My workcrs' conlpcnsation insurance carrier and prlicy numbcr arc: D Z. f1 .LZPolicy -l ccrtily that in thc Jrcrtbrmancc of thc work for which this pcrrnit is issued. I shall not cmpby any [rcrson in any manncr so as to bccome subjcct to thc workcrs'compcnsation laws of California, and agrec that if I should bccourc subject to thc workers' corrtpcnsation provisions of Scction 37fi) of thc Lrbor Codc. I shall. forthwith comply with those provlsions. WARNING: Failurc to sccurc workcrs'compensation coveragc is unlawful. and shall subjcct an employer to criminal pnalties and civil fincs up to onc hundred thousand dollars ($100,0m), in addition to the cost of compcnsation. damages as provided for thc Scction 3076 of thc l-atnr Codc, intercst and attorncy's fecs. 5 LICI'NS IiD C(IN]'RA C1'OR DI'CI ,\RA'I'ION r I hcreby al'flrrn undcr pcnalty of pcrjury that I arn licenscd under provision of Chaptcr 9 (conrmcncing with Scction 7000) of Division 3 of thc Busirtcss and Prolbssions Code, and my liccnsc is in full lbrcc and cffcct. LiccnseClass: o 6 Liccnsc Numbcr: D 6UetlD{q e W I hcrcby affirm undcr Jrcnalty of JErjury thal lhsc is a construction hnding agcncy for lhc pcrformrce of thc work for whhh this ltrmit Ls issucd (Scc. 3097, Civ. C.). lxndcr's Namc: [rndcr's Addrcss: A PPLICANT DF'CLARATION I hcrcby aflinn under pcnalty of perjury one of thc following dcclarations: DcnroIition Pcrnrits-Asbestos Notification Fcdcral Rcgulations (Titlc 40, Part6) -Rcquired l-cttcr of Notification -l ccrtify that thc fcdcral rcgulations rcgarding asbcstos rcmovalarc nol applicablc to lhis projcct.TJ )4tr""ify that t have read this application and statc that the atnvc inlbrrnarion is correct. I agrcc to comply ordittanccs and Statc Laws rclating to building construction, and hcrcby authorizc reprcscntativcs of this City with all City and County and County to enlcr upon thc abovc nrcntioncd propcrty for Applicant or Agent IDennilce namo \ Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf !oor/VenVl nsu I ati on Roof Sheathinq Shear Wall Framing Insulation/Enerqy Drywall Ext./lnt. Lath Brown Coat Nlasonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif -<fu,-- e^tc,u tlz q -1- 2t lfla.-.od,t FINAL Q -7 -Zt B^bl 9z Certificate of Occupancy Notes,Etc. -D Cori"r' rn ortu,t a.?rt77