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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hqcby aflirm undd poalty of pcrjury that I m cxcmpt 6om the Cootracto6' LiccN Law for thc followiog tten (Se.7031.5 Bwirs dd Profsion Codc): Aoy City or County which require a pomit to construct, alts, improvq dmolish or rcpair ay structuc, prior to its issuucc. also rcquirc thc applicmt for such pcmh to filc 8 signcd stst@ot that hc or shc b licoed plNet to thc provisioG of thc Contractor's Liccnscd [:w (Chaptc 9, Comcncing with Sation 7000 of Division 3 of thc Buincs ud Prcfsions Code) or that hc or shc is aempt thsefrom ud thc besis for thc allcged cxopion. Any violation of Serbn 7031.5 by a! applicantforapcmitsubjotsthc applicmttoacivilpmltyofnotmorcthilfivchundreddollm($500). -1, as owner of the prope'rty. or my employees with wages as thcir solc compâ‚¬nsation, willdo the work and the structure is not intended or offered for sale (Sec.7044, Business and hofessions Code: The Contractor's License [aw does not apply to an owner of the propoty who hrilds or improves thereon, and who does such work himself or herself or through his or her own employees. provided that such improvanents are not intended or offerod for sale. If, howwer. the building or imp,rovement is sold within one ]cur of complaion, the Orvner Builder will have the hrden of proving tha he or she did not build or improvc the propo'ty for the purpose of sale). _1. as owner of the propaly. am exclusively contracting with licensed contractors lo construct the proje.ct (Sec. 7044, Brsiness and Proftssion Code: The Contractor's License Law does not apply to an owner of property who builds or improves thcreon, and who contracts for such projects with a Contracto(s) licorsed pursuant to thc Contractor's License Law). -l am exempt under B. & P.C. for this reason. WORKERS' CONT PI'NSATION DE(]I,ARA'I'ION I hereby affrm under penalty of perjury one ofthe following declarations: -l have and will maintain a Certificate of Consent to Self-lnsure for workers' compensation, as provided for by Section 3700 of the I-abor Code. for the performance of the work for rvhich the perrnit is issued. _l have anwhich this permit is issued. My workers-' compensation insurance carrier and policy number are: S*r*B -Wthe work for I Carrier: poricyN"rrb"r, l qfZruUO^2O2o Expires: b9'241?Ozl -l certi& that in the performancc of the work for which this pcrmit is issued, I shall not employ any person in any manner so as to become subject to the workers'compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code. I shall. forthwilh comply with thosc provisions. WARNING: Failurc to secure workers'compansation coveragc is unlawful, and shall subject an anployer to criminal pcnalties and civil fines up to one hundred thousand dollars ($100.000). Section 3076 of the labor Code, intcrest and attorney's fecs. in addition to the cost of compensation. damages as provided for the F o*", e5'C{'b2 I I hereby affrm under poralty 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 full force and effect. License o c Nurnber:. /OOct@2_t I I hwby affm unda paslty of pcrjury thst th6c is a @Etruclion lcoding ag6cy for thc pcfomucc of thc work for which this pqmit b isued (Sa. 3097, Civ. C.). Lender's Name: Lcndcr's Ad&css: APII.ICANLDECI.aSAIION I h*by affm undq pcnalty of pcrjury onc of thc following delrations: Dqnolition PmitsAsb6tos Notifiâ‚¬tion Fedgal RegulatioN (Titlc 40. Pan6) -Rcquircd Lrtt6 of Notification -l cdiry thst the fcdcal rcgulatiore rcgrding rbctos moval uc not eplicablc to this projet, ldirolry ,n", f Urc md this applietion md statc rhar thâ‚¬ abovc itrfomdion is concl. I agre to @mfly with all City ud Couty odillffiG and Statc IiB rclding to huilding con*ruaioq and hccby authoriz rcprffit8rivG of this City ed County to otq upon thc above mcntioned property for inspection Applicant or Agent Pernrilec nflme t Drt", Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/Ve nul ns u latio n Roof Sheathing Shear Wall Framing Insu lation/Enerqy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif 1 FINAL ?,z9z,l (LclS^'tif.t,B "2rl Gertificate of Occupancy Notes, Remarks, Etc. -D o--^:--