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BUILDING- INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I lrcrcby affirm undcr pcnalty of perjury Ihul I am cxcmpl frcm lhc Conlroclors' Liccnsc liw for Ihe follouing rcarcn (Scc.?0{5 Busincss {nd Profcssion Codc): Any City or CounIy which rcquircs a lEmit lo s)nstruct. allcr. improvc, demlish or rcpair any slruclurc. prhr to its issuancc. alw rcquircs Ihc applicant lor such ,rrmil lo filc a signcd stilcmnl lhat hc or shc is liccnsd pursont to Ihc pmvi$ions of thc Contractor's Licenrcd hw (Chaptcr 9, Commencing with SEtion 7000 of Division 3 of thc Busincss and ProfcssionsCodc)orthothcorshciscrcmptthcrcfrcmandthebasisforlhcallcgcdcxcmption. Anyviolationofs6tionT03l.5byany applicunt for a pcrmit subjects thc applicant to a civil pcnalty of rot mrc than fivc hundrcd dollus ($50O). -1. as owncr of the propcrty. or my cnrployecs with wagcs as thcir solc conlpcnsation. will do thc work and thc structurc is not intcndcd or ofTcrcd for salc (Scc.7B4, Busincss and hofessions Codc: Thc Contractor's Licensc Law does not apply to an owner of thc pnrpcrty who builds or irnprovcs thcrmn. and who drrcs such work himsclf or hcrsclf or through his rlr her own cmployccs. providcd that such imllrovcnrcnls arc not intcndcd or offcrcd for salc. lt, howcvcr. thc building or irnprovctnent is sold within onc ycar of conrplction. thc Owncr Buildcr will have thc burdcn of proving that hc or shc did rrot build or improvc thc propcrly for thc purpnsc of sale). -1, as owncr of thc propcrty. anr cxclusivcly contracting with liccnscd contractors to construct thc projcct (Scc. 7U4. Busincss and ProfessionCode: The Contractor's Liccnse Law does not applyto anowner of propcrtywho builds or inrproves thcrcon, and who contracts for such prqccts with a Contractor(s) liccnscd pursuant to thc Contraclor's Licensc [aw). -I under B.& I)I'CI,ARA'I'I()N I hcrcby allirnr undcr pcnalty of pcrjury one of thc follow ing dcclarations: -l have and will nrairttafur a Ccrtificatc of Conscnt to Self-lnsure for workers' compcnsution. as providcd for by Scction 3700 of thc [:bor Code, for thc pcrfornuncc of thc work for which the Jrcrmit is issucd. -l havc and will maintain workers' compcnsation insurancc. as rcquircd by Scction 3700 of thc [:bor Codc. for thc pcrfornuncc of the work tbr which this permit is issucd. My workcrs' compcnsatiorr insurancc carrier and policy numbcr are: Policv Numbcr: Exnires: -l ccnify lhal in thc Jrcrfonmncc of lhc work for which this pcrmit is issucd, I shall not cnrploy any lErson in any mnncr s as lo bccom subjcct lo thc workqs' onrlrcnsation laws of Californiu. md lgrc that if I should bccotrc subjcct to thc workcrs' mmpcnsation pmvisions of Scction 3700 of Ihc titnr Codc, I shall, fonhwilh comply with tlbs prcvisions. WARNING: Frilurc to scure workcrs'compenstion covcmge is unlawful. dd shall subjet an emplo)rcr lo oiminul Fnrltics andi civil fincs up to ore hundrcd thousnd dollils (S100.0O0), in addition to lhc cost of compensation, daroges os providcd for thc Scctiorr 3076 of the l.abor Code. intcrest and attorrcy's fecs. Dale:7n2- ) / DECLARATION I hcrcby aftlrm undcr pcnalty of pcrjury that I am liccnscd undcr provision of Chaptcr 9 (conrnrcncing with Scction 7000) of Division 3 of the Busincss and Profcssions Codc, and my license is in full force and effcct. Liccnsc Class: Liccnse Numbcr: Date:_Contractor:_ W I hcrcby aflirm undcr Fnalty of pcrjury that thcrc is a <rnstruction lcnding {gcrcy for lhc pcrforure of thc work for which this lErmit is issucd (56. 3097, Civ. C.). Lcndcr's Narnc: [rndcr's Addrcss: APPI ICANT DECLARATION I hcrcby afiinn undcr pcnalty of pcrjury onc of the following dcclarations: Dcrnolition Pcrmits-Asbcstos Notification Fcderal Regulations (Title 40. Parr6) -Requ ired [*t tcr of Notilication -l ccrtily thal thc lbderal rcgulations rcgarding asbcstos rcrnovalare not applicablc to this projcct. -l ccrtily that I have rcad this application aftl statc lhal thc atnvc infornution with all City and County orulinanccs antl Statc l,aws rclating to building cotlsttuctiolr. and and County to cnter upon thc atxrvc rrrcntioncd proprty for Applicant or Agent Pernritce nanle Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenVl nsu lation Roof Sheathinq Shear Wall Framinq lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat lt/asonry Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif lA FINAL p/ nh,-1,frr^ Certificate of Notes, Remarks, Etc.I I , Applicarrt: