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SITE.WORK DATE rD/srQ\COMMENTS OWNER BUILDDR DEL(]ARATION I hqeby alfirm undd penahy of tEjury that I an cx.mpl from the ('onl.aclors' Liccnse ltw for the follorving reen (Sc.70-l1.5 Busin6s ild Profssion Code): Any City or County rvhich rcquirs a pemit to coNlmct. alto. improve. dqnolish or q*ir uy struclurc. prior to its issuece. al$ requirs the applicant for such pemit to lile a signcd statmmt thal hc or shc b licemed pmuol to lhc prcvisioG of the Contractor's Li@nsd liw (Chspter 9. Comencing rvith Setion 7000 of Division 3 of the Busincs md PrcfesionsCode)orthatheorsheisercmpttheeftomedthcb6isfortheallegedcxonplion. AnyviolalionofSerionT03l.5byany . applicant for a pcrmit subjects the applicant to a civil penalty of not more than live hundred dollars ($500). _1. as owner of the property, or my employees with wages as their sole compensation. rvill do the work and the structure is not intentled or offered for sale (Sec.7M4. Business and hofessions Code: The Contractor's License taw does not apply to an owner of the properly who builds or irnproves thereon. and rvho does such work himself or herself or through his or her own employees. pro;ided that such ilnprovanents are not intended or offered for sale. If. horvwcr. the building or improvement is sold within onc year of cornpletiorL the Orvner Builder will have the burden of proving tha hc or she did not build or improve the propoty for the purpose of sale). _1, as owner of rhe proper'ty. am exclusively contracting rvith licensed contractors to construct the project (Sec. 7044. Business and profiession Code: The Contractor's License Lar+. does not apply to an owner of property who builds or improves thercon. and who contracts for such projects with a Contracto(s) licensed pursuant to the Contractor's License Law). _l arn exempt under Section-. B. & P.C. for this reason. l)ittc:Owner:_ I hereby affinn under penalty of perjury one of the follorving _t have and rvill rnaintain a Certificate of Consent to Self-lnsure for rvorkers' conlpensation, as provided for by Section 3700 of the Labor Codc, for the perfonnance of the work for rvhich the permit is issued. -t have and rvill tnaintain workers' compensation insurance. as by Section 3700 of the Labor Code, for the performance of ,carrier and policy numbcr are:the work for which pennit is (l)I /lagPolicy o Numbcr'6 .ov /ot _l ccrtify that in the perfonnance of the work for rvhich this pennil is issued. I shall not so as to become subject to the rvorkers' compensation larvs of California. and agree that if I ernploy any person in any manner should become subject to the rvorkers' cornpensation provisions of Section 3700 of the Labor Code. I shall.fcrrthwith cornply with those provisions. and shall subject an onployer to criminal poralties andWARNTNG: Failure lo secure rvorkers' civil fines up to one hundre<l thousand darnagcs as providcd for the Section -3076 [abor('ode. interest 1{Lol< and attorney's fees. - I hereby aflirttr under penalty of perjury that I arn license<l unclcr of Chapter 9 (cotnrnencing rvith Section 7000) of Division 3 of the Business and Professions Code. and nry license is in full force and effect. License Class: : ,",",-t [ 7 t B License t 11]f1tg_(lontrrcto., f, I hereby affrrm under penalty of Srerjury that there is a construction issued (Sec. .1097. Civ. C.). agency for the po'fonnance of the rvork for rvhich this perrnit is Lender's Name: Lender's Address: APPLICAN'T DECI ARATION I htreby alfurn under penalty of pcrjury one of the follorving dcclarations: Dernolition Permits-Asbestos Notification Federal Regulations (Title 40. PaI16) -Required Letter of Notification _l csriS that thc federal regulations regarding asbestos retnoval are not applicable to this project. -l cerrify that I have read this application and state that the rvith all City and County and County to enter u1xtn theordinances and State Larvs relating to building above rnentioned property for inspeoion ,\pplicant or,\gettl Sigltatrrrc: )(. Pcrrttilcc nirrre (print): )(- C w,1@ Set Backs I :- )- lol ^/ ,(, ? Forms/Steel/Holdowns Erection Pads tg UFER Ground /-t SLAB Floor -,A,Subfloor ftD,J l c r- l7-lo Roof Sheathing a | -y-lol Y Shear Wall Framinq (E lnsulation/Energy 'u7y-17 Drywall 0 I )-o*TC, Ext./lnt. Lath 7 \J Brown Coat Masonry , Pool Fence I T-Bar I 14 VTlt Handicap Req Deputv Final Report Enqineer Final Report Flood Zone Certif I t\ t FINAL lt Certificate of Occupancy \,v Notes, Remarks, Etc.\ + BUILDING. INSPECTOR RECORD {t txlt lr/(. a ?'1 Le 1 \J l-l >n