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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DEI,CARATION I hscby aflim undr pcnalty of pcrjury that I m â‚¬xmpt fiom thc Contrdcloc' Licmc law for thc following rcon (S6.703!t B6io6s ard Profsion Codc): Any City or County which rcquim a pomit to coNtruct, 8ltq. improvc, &rmlish or rglr uy structe prbr to its isurec also rcquirc thc applicet for such Fnnil lo filc a signcd statmot thst hc or $e b liccnscd pEWt to lhc pmvisioro of thc Contractor's Liccnscd taw (Chaptd 9. Commcncing with Setion 7000 of Division 3 of thc Busins ed PrcfesionsCode)orthathe orsheisexcmptih@fromildthcb8isfortheallcgcdexmpion. Any\iolationofSationT03l.5byilt, applicantforapcrmitsubjststhe applicuttoacivilpcnaltyofnotmorcthelivchundreddollas($500). _1. as owner of the property. or my employees with wages as thcir sole cornposation. will do the work and the structure is not intcnded or oflered for sale (Sec.7044, Business and Professions Code: Thc Contraclor's License Law does not apply to an owner of the prcperry who hrilds or improves theron. and who does such wo* himself or herself or through his or her own employees, provided that such improvements are not intendcd or offerod for sale. l[, howet/er. the building or improvement is sold within one year of complaion, the Olvner Builder will have the hrden of proving tha he or she did not build or improve the property for the purpose of sah). -1, as owner of the property, am exclusively contracting with licensed contraclors to construct thc prolect (Sec. 7M4, Business and Profession Code: The Contractor's License l,aw does not apply to an owner of property who builds or improves thereon. and who contracts for such projects with a Contractor(s) licoucd pursuant to the Contractor's Liccnsc Law). --IamexemptunderSection--lB.&P.C.forthisreason. Date:_O*nert WORKERS'COMPENSATIM - DECLARATTON one of the following declarations:I hereby alTirm under penalty of per1ury _l have and will maintain a Ccrrilrcate of Conscnt to Self-lnsure for workers' compensation. as providcd for by Section 3700 of the Labor Code. for the performance of the work for which the pennit is issued. -l have and will maintain workers' compensation insurance. as required by Section 3700 of the l-abor Code. for the performance of the work for which this permit is issued- My workers' compensation insurance carrier and policy number are: .a Policy _l certify that in the performance of the rvork for which this permit is issued. I shall not ernploy any pcrson in any manne: so zrs to bccomc subject to the workers' compensation laws of California. and agree that if I should become subject to the a rvorkers' compensation provisions of Section 3700 of the Labor Code. I shall. forthrvilh comply with thosc provisions. WARNING: Failure to secure workers' compensation coverage civil fines up to one hundred thousand dollars ($100.000), in is unlawful. and shall subject an criminal$aralties and to the of as provided for the Section 3076 Labor interest and fees. I hereby affirm under penalty of perjury that I am licensed 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code. and my license is in tull force and effect. License + Number: W I hrcby afiim unda Fnalty of pqjury thal thqc is I @nstruclion landing agrey for thc [EfoImcc of thc mrl for which this p6mil b issucd (Sa. 3097. Civ. C.). Lndtr's Nmc: Lender's Address: APPLICANT DECLAITATION I hoâ‚¬by aflirm under penalty of perjury one of the following declarations: Demolition Perrnits-Asbestos Notification Federal Regulations (Title 40, Part6) _ _Required Lettcrof Notification _l certi& that thc federalregulations regarding asbestos removalare nol applicable to this proJed. state that the ahrve information is correct. I agree to comply with all City and County abcve mentioned property for Applicant or.A,gent Pernritee nanre and of this City and County to enter upon the Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloor/Ve nUl ns u lation Roof Sheathing Shear Wall Framing Insulation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif I FINAL 7/z A/2,o74 ,.7ffi \ Certificate of Occupa ncy /'(_/ Notes, Remarks, Etc. / ,**, \ ^vwv\ un zvv\( ln 4 frD ^,", lzlqllq a