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SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby aflirm undcr pcnalty of pcrjury thal I am cxcmpt frcm lhc Conlrnclors' Liccnse hw for thc following rcamn (Sa.7031.i <br />Busirrcss and Profcssi(rn Codc): Any City or County which rcquires a Jrcrmit lo onstrucl. allel improvc, domlish or rcpair uny <br />struclurc. prior to its issuance. also rcquircs the applicant lbr such JErmit to filc a signcd slalcmnl thal hc or shc is liccnscd pirsuilnt <br />lo lhe pmvisions of llrc Conlraclor's Liccnscd kw (Chaptcr 9, Commercing wilh Scclion ?(nO of Division .1 of lhc Busincss and <br />Pmfcssions Code) or thal hc or shc is cxcnrpl lhcrcfrom and thc basis for thc allcgcd cxcmption. Any violation of Sccthn 70-1 I .5 by any <br />applicant for a pcrmit suhj$ls lhc applicanl to a civil pcnalty of not mrc lhan livc hundrcd dollars ($50O). <br />-1. <br />as owner of the proprty. or my employccs with wagcs as thcir sole conr;rcnsalion. will do thc work ilnd thc struclurc is nol <br />intendcd or offered lirr salc (Scc.7044. Busincss and Profcssions Code: Thc Conlraclor's Liccnse [-aw docs not apply lo an owncr o[ <br />thc pnrJrcrly who builds or inrprovcs thcrcrrn. and who docs such work himsclf or hcrsclf or lhrough his or hcr own cntplol'ces. <br />providcd that such impnrvcnrcnts arc mrt inlcndcd oroffcrcd frrr srh. If. howcvcr. thc building or inqrrovcrncnt is sokl within onc year <br /><lf conrphtion. thc Owncr Buildcr will havc thc hurdcn of proving that hc or shc tlid n<lt build or inrprovc thc propcrty lirr thc purlnsc ol' <br />salc). <br />-1. <br />as owner of the property. am exclusivcly conlractilrg with liccnsed conlrilclors lo conslrucl lhc projcct (Scc. 7(A4. Busiltcss <br />arrd Pnrftsskrn Codc: 'l'hc Contractor's Liccnsc Law does not apply lo an owncr o[propcrty whrt builds or itnprovcs lhcrcon. <br />and who contracts l'or such projecls with a Contractor(s) liccnsed pursuanl to lhe C<lntraclor's Licensc l-aw). <br />-lamcxemptundcrSection-.B.&P.C.forthisrcason.I)ale:Owner:- <br />lVORK I.' RS' COi\I PIiNSAI'ION <br />I)FCLAIIA'TI()N <br />I hcrchy all'irrn undcr pcnllty of pcrjury onc of thc following <lcclarations: <br />-l <br />havc and will nraintain a Certificatc of Conserrt to Sclf-lnsurc tirr workcrs' conrpcnsation. as providcd lbr by.Sccliolt 3700 of thc <br />labor Codc. for the pcrfonnance of thc work for which thc pcrnrit is issucd. <br />-l <br />havc and will nraintain workcrs'conrJrcnsation insurancc. as rcquired hy Scction 3700 of lhc l-abor Codc. for thc pcrformancc ol' <br />u'ork lirr which this pcrrnit is issucd. My workcrs'and Jnlicy lrurnbcr are: <br />t a <br />re_ <br />(r,,,,., <br />_l ccrtify that in thc pcrfornrance of thc u'ork for which this pcrrnit is issucd. I shall not crnploy any person in any tnanncr <br />so ils to hcconrc suhjcct to thc workers'cornpcnsation laws of Calilbrnia. antl ugrcc thal if I should hcconrc subict lo thc <br />workcrs' cornpcnsation provisions of Scction .17()0 of thc l-ahrr Codc. I shall. ltrrthwith conrply wilh those provisions. <br />WARNING: Failurc lo sccure workcrs' cornpcnsation covcragc is unlawful. arrd shall subjccl an cnrploycr to crintittal lrcnahics attrl <br />civil lincs up to onc hundrcd thousand dollars ($l00.UX)). in addition to lhc cost of contpcnsalion. danugcs as providcd lirr lhc <br />Sccliorr J07(r of thc and atlorney's l'ces. <br />I hcrcby aflirnr undcr pcnalty of pcrjury that I anr licenscd unrlcr provision of Chaptcr 9 (conrnrcncirrg with Scction 70(XD of Division .l <br />of thc Busincss and Profcssions Codc. tml my license is in full l'orce and cflbcl. <br />Nurttlrcr: <br />Hrntracror:W <br />I hcrchy aflirm undcr FrcnallyofJErjury thal lhcrc is a conslruction hnding agcncy for the perforftrncc ofthc work fur which lhis frcrmit is <br />issucd (Scc. 3097. Civ. C.). <br />[rn<lcr's Nanrc: <br />L,cndcr's Address: <br />APPLICANT DECLARA'TION <br />I lrrchy aflirnr undcr pcnalty of pcrjury orrc of the following dcclarations: <br />Dcnmlition Pcrmits-Asbcstos Notification Fcdcral Regulations (Titlc 40. Parl6) <br />_Rcquircd lrttcr of Notification <br />-l <br />ccrtify that thc fcdcralregulations rcgnrding asbcstos rcnrovalare not applicablc lo lhis projcct. <br />tI' I certily that I have rcad this application and state thal thc ahrve inlbrnration is correcl. I agrcc to cornply <br />ordinanccs and State [:ws rclating to building conslruction. and hercby authorizc reprcsentatives of this City <br />with all City and County <br />and County lo enter uJxrn lhc <br />atxlvc nrcntioncd propcrty for inslrcction purF)ses. <br />(pr""nt)or Agent Sigrr:rlrrre: <br />1 Pennitee nanre (print):4^",-lfnflg <br />Set Backs <br />Forms/Steel/Holdowns (is/27/r<>N66 <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf Ioor/VenVl nsu lation <br />Roof Sheathing <br />Shear Wall 'l/ ?.6 / t"i ;\na <br />Framing q/l4ta 5N# <br />lnsu lation/Energy dhs,/rp t -ild*./'6> <br />Drywall (/t'- <br />f- ./ <br />q.*k <br />Ext./lnt. Lath (- -/ l{I rur1>l <br />Brown Coat <br />N/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />^/ ///a <br />FINAL Trlr'/UrIZI Mffi <br />Certificate of Occupancy <br />Etc. <br />,/g -l v <br />BUILDING- INSPECTOR RECORD <br />! <br />i$ate: <br />------<t- <br />/ <br />/