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INSPECTOR RECORD SITE-WORK DATE !D/SIG.GOMMENTS OWNTR BUILDER NFLCARATION I hereby affinn under penalty of periury that I am exempt form the Contractors' License Law for the following reason (Sec.70-11.5 Business and Profession Code): Any City or County which requires a permit to construct. altcr. improve, demolish or repair any structure, prior to its issuance. also requires the applicant for such permit to file a signed statement that hc or shc is licerued pursuant to the provisiors of the Contractor's Licensed Law (Chapter 9. Commencing with Section 7000 of Division 3 of the Business and Professions Code) or that he or she is excmpt therefrom and the basis for the alleged exemption. Any violalion of Section 70-3 I .5 by any applicant for a perrnit subjecs the applicant to a civil penalty of nol more than five hundred dollars ($500). [-t. .. owner of rhe property. or my ernployees rvith wages as their sole compensation, will do the rvort and the structurâ‚¬ is nor intended or offered for sale (Sec.7044. Business and Professions Code: The Contractor's License Law does not apply to an owner of the foperty s'ho builds or improves thffeon. and rvho dcres such wort himself or hcrself or through his or her own cmployees. provided that such improvonents are not intended or offered for sale. If. however, the building or improvement is sold within one year of completion, ttre Owns Builder uill have the burdcn of p,roving that he or she did not build cn improve tre propertv for he purpGc of sale). I! l. ". o\.r,ner of rhe prope'rty. am exclusively contraoing u'ith licensed contraclors to constnrct the project (Sec. 7044. Business and Profession Code: The Contractor's License l-arv does not apply to an os'ner of property rvho builds or improves thereon. and who contracts for such pro.iects with a Contracto(s) liccnsed pursuant to the Contractor's l,icense Law). lo-l ,tr', exempt under Section -B. & P.('. for this reason. WoR.KFRS' COMPFNSATION nFCl ^ RATION I hereby alTinn under penalty of perjury one of the following declarations: ! I f,r". ancl will maintain a Certificate of Consent to Self-lnsure for workers' compensation, as provided for by Section 3700 of the L:bor Code. for the performance of the work for which the pernrit is issued. YES _l have and will maintain wortcrs' compensation insurance. as required by Section -1700 of the l-abor Code, for the perfornrance of the rvork for which this perrnit is issued. My workers' compensation insurance carrier and policy number are: . Cyprrr lnrurance Company( arrer: Policy Number:_ NO _Expires: _ I certify that in the prformance of the work for s'hich this perrnit is issued. I shall not cmploy any person in any manner so as to become subject to the wod<ers'compensation laws of California. and agree that if I should become subject to the workcrs' compâ‚¬nsation provisions of Section 1700 of the Labor Code. I shall. forthu'ilh comply'with those provisions.. WARNING: Failure to secure workers' compensation coverage is unlawful, and shall subiect an employer to criminal pcnalties and civil Iines up to one hundred thousand dollars ($100.m0). in addition to the cost of compensation. damages as provided for the Section 3076 of the Labor Code. interest and attomey's fees. LICFNSFN CONTR ^ CTOR NF'('I AR.ATION I hereby affinn under penalty of perjury that I am licensed under provision of Chapter 9 (commencing with Section 7000) of Division -j of the Business and Professions Code. and my licerrse is in full force and effect. c37 License ('lass:7754C3 [,icense Number CONSTRII('TION I FNDING AGFNCY I herebl, affinn under penalty of per.fury that there is a construction lending agercy for the performance of the work for which this permit is issued (Sec. 3097. Civ. C.). Lender's Name: lrnder's Address: \ APPT I("{NT NT'CI A.ITATION I heretrv allinrr under penalty of per.;ury one of the followrng declarations: Denrolrtron Pernrrls-Asbestos Notrlicalion Federal Regulatrons (Title 40, Part6) !o Required l-etterof Notification YT f cerliB/ that the federal regulations regarding astrcstos removal are not applicable to this project. ttt f ceai$/ rhat I have read this application and state that the above information is correct. I agree to cornpty with all Ciry and Coturty ordinances and State Larvs relating to building construction. and hereby authorizc r@rescntatives of this City and County to cnter rpon the above mentioned property for inspection purposes. Reroof Roof (Diaphragm Sheathing/Frame) Structural Final Plumbing I .tl Under FIoor I Under Slab q -,-yl tJ*w f( Rough Shower Pan / Tub Test Water Service Sewer / Sewer Cap Gas Air Pressure Test a I t,Dtlt#,7 Plumbing Final Electrical Service (Meter I Panel) Grounding / Bonding Rough Electrical Final Mechanical Gas Air Pressure Test Rough Piping (HW, CW, etc.) Exhaust Ducts Mechanlcal Fanal t t\A ,^, (,I w a T Dfi.+fl I I Notes, Remarks, Etc. 071o112022 a // J