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INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BTIII NFR DFLCARATION I hereby affinn under penalty of perjury that I am exonpt form the Conffactors' License Law for the following reason (Sec.7031.5 Business and Profession Code): Any City or County which requires a pcnnit to construct. alter. improve. demolish or repair any structure. prior to its issuance. also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to thc provisions of the Conractor's Licensed l.aw (Chapter 9. Commencing with Section 7000 of Division -1 of the Business and Professions Codc) or that he or sheisexempttherefromandthebasisfortheallegedexemption. AnyviolationofSectionT03l.5byanyapplicantforapennitsubjecsthe applicant to a civil penalty of not more than five hundred dollars 1$.500). !o-t. ,t owner of the property. or my employees with wages as their sole compensation, will do the wort and rhe structure is not inrcnded or offered for sale (Sec.7044. Business and Professions Code: The Contractor's License Law docs not apply to an owncr of the propcrty who builds or improves theteon. and rvho does such work himself or herself or through his or her own cmployees. p,rovidcd that such improvonents arc not intended or offered for sale. lf. howerrer. the building or improvement is sold within one year of complaion. the Orvner Builder rvill have the burden of proving that he or she did not build or improve dre property fcr the purposc of sale). xo-1. at owner of rhe property. am exclusivety contracting with licensed contractors to construct the project (Sec. 7044. Business and Profession Code: The Contractor's l,icense [-aw does not apply to an owner of property who builds or improves thereon. and rvho conlracts for such proiects rvith a Contractor(s) licensed pursuant to the Contractor's License Law). rc-t am exempt under Secrion . B. & P.C. for this reason. woR.KrRs' CoMPENS {TION nFCl ^ RATION I hereby alTirm under penalty of perjury one of the following dcclarations: rc I h.*,. and will maintain a Certificate of Consent to Self-tnsure for workers' compensation. as provided for by Section 3700 of rhe Labor Code, for the performarce of the work for which the permit is issued. YE6 -l have and will maintain rvorkers' compensation insurance. as required by Section -1700 of the Labor Code. for the performance of the work for which this permit is issued. My worters' compensation insurance carrier and policy number are: . 9ccurlty Natlonal( arTrer: swc1307380l'olicv Nrrrtther._Expires: 1112312021 NO _ I certifu that in the performance of the work for rvhich this permit is issued. I shall not employ any percon in any manner so as to become sub.iect to the workem' compensation laws of California. and agree that if I should become subject to the workcrs' compensation prrrvisions of Section 3700 of the Labor Code. I shall. forthrvith comply with those provisions.. WARNING: Failure to secure rvorters'compensation coverage is unlawful. and shall subject an onployer to criminal penalties and civil fines up to one hundred thousand dollars ($100.000), in addition to the cost of compensation, damages as provided for the Section .1076 of the Labor Code, interest and attorney's fees. I ICTNSTN CONTRAC'I'OR NFCI {RA'TION I hereby alTirm under penalty of perjury that I am licensed undcr provision of Chapter 9 (cornmencing rvith Section 7000) of Division -3 of the Business and Professions Code, and my license is in full force and effect. c2o-c30 l-icense ('lass:78'f495 l,icense Number (.ONSTRUCTION I TNUNG AGFNCY I hereby affinn under penalty of perjury' that there is a construction lending agerrcy for the perfonnance of the work for which this Jrermit is issued (Sec. .1097. Cir,. C.). [.ender"s Name: l-ender's Address: APPr ICANT nFCt ^RrdrtON I herebv affimr under penalty of per1ury one of the followrng declarations. l)enrol ttion Penttrts-Asbeslos Notr ticatron Federal Regul atrons (Title 40, Part6 ) p_ Required Letterof Notification YEs f cerlifo that the federal regulations regarding a-sbestos removal are not applicable to this project. ttt t certiS, that I have read this application and state that the atrrve informarion is correct. I agree to comply wirh all City and Cotmty ordinances and State Laws relating to building construction. and hereby authorizc representatives of this City and County to enter upon the above mentioned property for inspection purposes. Reroof Roof (Diaphragm Sheathing/Frame) Structural Final Plumbing Under Floor I Under Slab Rough Shower Pan / Tub Test Water Service Sewer / Sewer Cap Gas Air Pressure Test Plumbing Final Electrica! Service (Meter I Panel) Grounding / Bonding Rough Electrical Final Mechanica! Gas Air Pressure Test Rough Piping (HW, CW, etc.) Exhaust Ducts tl Mechanical Final tbl trlT t7 ts 99 I I Notes, Remarks, Etc. a