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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION I hcrcby allrm undcr Fnalty of Jrcrjury that I am cxcmpt from thc Grntract)N' Liccn$ llw lor thc folk)wing rcasrn (Se.70.! 1.5 Busincss arrl Professiru Gxlc): Any City or County which rcquircs a lErmit k) construct. altcr. improvc. dcmolish or rcpai, any slruchrc, Jri)r b its issuancc, also rcquircs Ihc at plicanl for such lrcmil b filc a signcd slrtcmnl lhat hc or shc is liccnsd p$uanl to thc Fovisions of lhe Conlracklr's Liccnscd law (Chaplcr 9, Commncing with Sslhn ?(X)0 of Division 3 of thc Busircss and Prcfbssions Culc) or thal hc or shc is cxcmpt thscfrom and thc basis for thc allcgcd crcmplbn. Any violalion of Sction 70.1 1.5 by any anplicatrl for a lErmil subjels lhc al,plicatrI b a civil pcnalty of trot mrrc than fivc hundred dolltrs (S500). _1, as owncr of thc propcrly, or my cmployccs with wagcs as thcir solc conrpensation, will do thc work aftl the structurc is not intcmled or ot'lcrcd lilr salc (Scru.7044. Busincss and Prot'cssions Crxlc: 'fhc Contractor's Liccnse Law does not apply to an owncr of thc pnlpcrty who builds or impn)vcs thcrcon, and who drrcs such wrlrk himsclf rlr hcrsclf or th()ugh his or hcr own cmployccs, providcd that such improvcrncnts arc not intcndcd rlrollbrcd tbr salc. It, howcvcr, thc huilding or improvcrncnt is sold within onc ycar ol complel.ion, thc Owner Buildcr will havc tlrc burtlen of proving that hc or shc did mrt build or improvc thc proJrcrty lilr thc purJxtrc ol' salc). _1, as owncr of thc proprty, am exclusivcly contracting with liccnscd contractors to construct the project (Sec. 704/', Busittcss and kutbssion Codc: Thc Contractor's Liccnsc Law docs not apply lo an owncr of propcrty who builds or improves thcrcon. and who contracts lilr such pnljccts with a Contract<lr(s) liccnscd pursuant to thc Contractor's Liccnsc Law). -IanrexemptundcrS..ctitllt-'B.&P'C.ttlrthisrcastln.f \..r ^. }VORKERS' CONI PT]NSATION DECI,ARATION I hcrchy atlirm undcr Jrcnalty ol'Jrcrjury onc ol'thc kllklwing dcclarations: _l havc and will maintain a Ccfiillcatc of Crurscnt to Selt'-lnsurc firr workcrs' comJrcnsatron, as providcd for by Scction .37fi) ol'lhc Lahlr Codc, lilr thc ;rcrlirrmancc ol'thc wrlrk ftlr which thc pcrmit is issucd. _l havc and wrll maintain workcrs' compcnsation insurancc, as rctluircd by Scction -]700 of thc Lahor Codc, lilr thc Jrcrlirrmancc of lhc wrlrk tirr which this 1^-rnrit is issucd. My ;iffi insurancc caricr and plicy numbcr are: .1- .R v, \ic I trt Policy tt rDlt I 4J _l ccrtity that in thc Jrcrlirrmancc of thc wrlrk tilr which this pcrnrit is issucd, I shall not cmploy any pcrson in any manncr so as to becomc subjcct to thc workcrs'comJrensation laws of Calitilrnia, and agrcc that if I stxluld becomc subjcct to thc workcrs' comJrcnsation pnrvisions o[ Scctirln J700 of thc Latxrr CrxJc, I shall. tilrthwith comply with t[xlsc provisions. WARNING: Failurc to sccurc workcrs'com;rcnsation covcragc is unlawl'ul, and shall subjcct an cmpkrycr to criminal Jrnaltics and civil lincs up to onc hundrcd thousand dollars ($1ffi,fi)O), in l<l lhc cosl ol'comJrcnsation, damagcs as providcd lirr thc Scction 3076 of thc Lahrr Gxlc, inlcrcsl and I\.rr^. LICENSED CONTR/|CTOR DECLARATION I hercby atfirm undcr Jrcnalty ol'pcrjury that I am liccnsed under pnrvision of Chaptcr 9 (commcncing with Scction 7000) of Division .] of thc Busincss and Pnll'cssi<lns Codc, and my liccnsc is in t'ull lirrcc and cll'cct. Liccnsc 5 65 1Z5a WthcEbyafftrmundcrJEnallyofJrcrjurythartrro"iryrformcofrhcmrkforwhichthisImitis. issucd (Se. 3097, Civ. C.). kndcr's Namc: hndcr's Atldrcss: APPLICANT DECLARATION I hcrcby atlirm undcr pnalty of pcrjury onc of thc lirlkrwing dcclarations: Dcmoliti<ln Permits-Asbcstos Notification Fcdcral Regulations (Titlc 40, Part6) -Rcquired lrttcr of Nolilicalion _l certily that thc t'cdcralrcgulations rcgarding asbcstos rcmovalarc not applicablc lo lhis prljcct. aml statc that the atxrvc inlirrmation is corrccl. I agrc.c to comply with all City and County arl(l hercby auttxrrize rcprcscrrtativcs of this City and County to cntcr uSxrn the atxlvc mcntioncd propcrty tirr Applicant or Agent \ l)crnritee nanle construction, \Dare:\l*/u7 Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenUI nsu lation Roof Sheathing Shear Wall Framing Insu Iation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif FINAL /-,a-.21 bno*a Certificate of Occupancy Notes, Remarks, Etc. Elrrv nQ-n7 -2n1q /I I