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BU!LDING. INSPECTOR RECORD S!TE.WORK DATE !D/S!G COMUEIiITS OWNER BTJILDER DEI,CARATTON I hscby rffinn undcr pcnally of pcrjury that I m cxcmpl from thc Contradots' Licens lrw for thc following rcason (Scc.7031.5 Bsiness snd Profcssion Codc): Any City or County which rcquira a pcmit to construct, alto, improvc. dcrnolish or rcpair any structwc. prior lo its issuncc. also rcquic thc spplicant for such p.mit to filc I signcd statcmcnt that lE or shc is liccNcd puGuant to thc provisions of thc Contractor's Licensed taw (Chaptcr 9, Commcncing with Scction 7000 of Division 3 of thc Busincis and Prcfcssions Code) or that hc or shc is crcmpl lhgcFom and thc basis for thc allcgcd cxmptioo. Any violation ofsfflion 703 I .5 by any applicant for I pcmit subjcts thc applicant to a civil pcnalty ofnot morc than fivc hundrcd dollars (9500). - l. as owner of the property. or my employccs with wages as their sole compensation. will do the work and the structwe is not intended or offered for sale (Sec.7044. Business and Profcssions Code: The Contractor's License Law does not apply to an owner of the property who builds or improves thereon. and who does such work himself or herself or through his or her own employees. provided that such itnprovcments are not intcnded or offered for sale. If. however. the building or improvement is sold within one year of completion. the Orvner Builder rvill have the burdcn of proving that he or she did not build or improve the property for the purpose of sale). - l. as owner of the property, am exclusive ly contracting with licensed contractors to construct the proiect (Sec. 7U4, Business and Profcssion Code: 'fhe Contraclor's l,icense Law does not apply to an owner of property rvho builds or improves thereon. and who contracls ficr such projects with a Contracto(s) licensed pursuant to the Contractor's License Larv). _l am exempt under Section_. B. & P.C. for this rcason. ( )rr nrr': WORKERS' COMPENSATION DECLARATION penalty of perjury one of the following declarations:I a Certificate of Consent to Self-lnsure for workers' conrpensation, as provided for by Section 3700 of the of the work for which the pennit is issued. _t the workers'.f 700 of the l.abor Code. for the perfonnance of is and policy nunrber are: Polic-v-3 -r.***4f 1 'l lb /_l in the performance of the u'ork for which this perrnit is issued. I shall not employ any person in any manner subject to the workers'conrpensation laws of California. and agree that if I should become subject to theso as to rvorkers'provisions of Section .1700 of the [abor Code. I shall. forrhwith comply with those provisions. WARNINC: Failure to secure workers' cornpensation coverage is unlawful. and shall suhject an employer to criminal penalties and civil fines up to one hundred thousand dollars ($100.000). in addition to the cost of cotnpensation. danrages as provided for the Section the Code. interest and attorney's fees. D[.('l.AltA'I'toN I hereby affrrm under penalty of perjury that I am licensed under provision of Chapter 9 (comrnencing with Section 7000) of Division 3 of the Business and Professions Code. and my licensc is in full force and effect. License Class: -License Numbe, I C C bbQT I hereby aflirm under penalty of perjury that there agency for the perfonnance of the rvork for rvhich this pennit is issued (Sec. 3097. Civ. C.). Lender's Name: APPLICANT DECLARATION I hercby affrnn under penalty of perjury one of the following declarations: Demolition Permits-Asbestos Notification Federal Regulations (Title 40. Part6) _Required Letter of Notification -l certify that the federalregulations regarding asbestos removalare not applicable to this project. and state that the above information is correct. I with all City and County and County to enter upon theconstruction.hereby authorize above mentioned property for ,,,,, itl tor// {Applicant or Agent Signature: t.-1. have zurd Code. and will '1 for Pernritee nAme (print): purposes. .} Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/Ve nUl n s u lation Roof Sheathing Shear Wall Framing lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry --Pool Fence I T-Bar Handicap Req.\ Deputy Final Report \ Engineer Final Report \\ Flood Zone Certif.\\,/ g b e/f42.r/rz /lN ?+)4 A.h^/E ))\,//\ FINAL \ Certificate of Occu Etc. \ \\ Rev. 08-07-2015 a Dete:_ Lender's Address: ordinances and State l-arvs relating E->