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B !LDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.CUmMENTS Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/Ve nUI n s u latio n Roof Sheathins 10-1-Zl r(J h) Shear Wall \-/ Framinq lnsulation/Energy Drnruall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req. Deputv Final Report Enqineer Final Report Flood Zone Certif , FINAL lo/tzlu fZut lq Certificate of Occupancy Notes, Remarks, Etc. OWNER BUILDER DEI'ARATION I hscby affm undo poralty of perjury that I m cxmpi iom thc Crntraclo6' Licw Law for thc followiry r@n (Se.7031.5 Busin6s ed Profeion Code): Any City or Couty which rcquire a pannit to @mtruct, alt6, improvc, danolish or ropair my struciurc, prior to its issumcc, also rcquirc thc appli@t for such p6mit to filc I signed strlmdt thar hâ‚¬ or Sc b liccnscd p|Net to thc provisiore of thc Contractor's Licmscd bw (Clnpts 9, Comocing with Sclioo 700O of Divisioo 3 of thc BBiB ffd Profsions Codc) or that hc or shc is qcmF rhqcfrom ed thc bosis for thc allcgcd cxoptio[ Any violstion of Sction 7031.5 ty my applicant for a pctmit subjcts thc applicmt to a civil pmlty of nol morc tho fivc hundrcd dollm ($500). _1, os owner ofthc property, or my employees with wages as their sole compensation, will do the work and tlrc struclure is not intcnded or offered for salc (Sec.7044, Business and hofessions Code: The Contractor's Licerue Law does not apply to an owner of thc propcrty who hrilds or improves theroon and who does such work himsclf or hcrsclf or through his or her own employccs, provided that such improvonents are not intendod oroffcrod for sah. I(, howcvcr. the buildiug or impmovanrent is sold within one )â‚¬ar of complaioru the Orvner Builder will have thc hrdâ‚¬n of proving tha he or she did not build or improve the propoty for thc purposeof sale). _1, as owner of the p,ropcrty, am exclusively contracting with licensed contractors to construct the projcct (Sec. 7044, Buiness and Pnofcssion Code: The Contractor's Licensc Law docs not apply to an owner of property who builds or improves thcreon, and who contracts for such projects with a Contracto(s) liccrscd pursuant to thc Contractor's License taw). -l am cxempt under Section-, B. & P.C. for this reason. I hereby alTirm under penalty of perjury Owner: WORI("RS' COMPENSAT DECI.AITATION one of the following declarations: _l havc ald will mhtain I Cqtifiete of Comt to SclfJrourc for wrk6' composalion, c provided for by Sction 3700 of thc tabor Codc, for thc pqfomcc ofthc work for which thc pqmit b issucd. $ havc ud will maimah work6' compcnstion irmncc, s requircd by Sction 3700 of thc labor Codc. for thc psfoIrmcc of lhl rcrk for which this pcrmit is ised My workc' compqsdion iremcc oia ad policy numb< rc: <#^+â‚¬ n nnr^l Policy 4Dt (o t"o (a(fo3 -l ccrti& that in the pcrformance of thc work for which this pcrmit is issued, I shall not employ any pcrson 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' cornpensation provisions of Section 3700 of the labor Code, I shall, forrhwith comply with those provisions. WARNING: Failure to secure workers' compensation coveragc is unlawful, and shall subject an ernployer to criminal poralties and civil fines up to one hundred thousand dollars ($100.000), in addition to the cost of compensation. damages ali providetl for the Section 3076 of the tabor Code interest and attorney's fees. ou", Lo I ro 12 | I hereby aflirm under poralty of perjury that I arn licensed provision of Chapter 9 (commorcing with Section 7000) of Division 3 of the Business and Professions Code. and my license is in full force and effect. Liccnse C tO v '2- \ W I hwby afiim uda pcrnlty of pcrjury thrt th@ is a onnruaion lmding agmy for thc pcfotmcc of thc worl 6r which this psmit b isucd (Sc. 3097, Civ. C.). lcnds's Nme: Lcndcr's Address: APPLICANT DECLARATION I herebr)/ afnrm under penalty of perjury one of the following declarations: Demolition Permits-Asbestos Notification Federal Regulations (Title 40, Part6) -Requircd trtter of Notification _l certi& that the federalregulations regarding asbestos removal are not applicable to this project. _l certi& that I havc read this application and state that the above inflormation is correct. I agrec to cornply with all City and County ordinanccs and State l-aws relatirry to construciiorL and hcreby authorize reprcsentatives of this above mentioned property for ; Applicnnt or Agent Permitee n&nle City and County to enter upon the Lo I t' (zr v -â‚¬