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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATTON I hrcby aflirm undcr poralty of perjury thar f m cxcmp ftom thc Contracton' Licffi tiw for thc foltowing rwn 1Se.f0il.5 Bsinss md Profsion Codc): Any City or Coutrty which requirs a po'mit to construct, altc. improvq dmolish or repair uy struclrc, prior to its issuucc, also rcquiG the spplicilt for such pemil to filc I signcd statmot that hc or strc is lic$cd puuut to thc prcvisiom of thc Contractor's Liccnscd Law (Chapts 9. Commocing with Sstion 7000 of Division 3 of the BEine$ ed Prcfesions Code) or that he or shc is cxcmpt th@fiom ed thc basis for the alleged cxmption. Any violation of Sdion 7031.5 by any applicantforapcmitsubjctsthc applicattoacivilpcmltyofnotmorcthmfivehundrcddollm($500). _1. as owner of thc property. or my employees with wages as their sole compensation. will do thc work and the structure is not intended or offered for sale (Sec.7M4, Business and Professions Code: The Contractor's License Law does not apply to an owner of thc property who builds or improves theroon. and who does such work himself or herself or through his or her own employees. provided that such improvanents are not intended orofferod for sale. If, howet/er, the building or improvement is sold wilhin one year of complaion, the Owner Builder will have the burden of proving ttrrat he or she did not build or imp,rove the propo'ty for the purpose of sale). -1, as owner of the property, arn exclusively contracting with licerued contractors to construct the project (Sec. 7U4, Business and Pnoftssion Code: The Contractor's Licensc Law does not apply to an owner of property who builds or improves thereon. and who contracts for such projects with a Contracto(s) licensed pursuant to the Contractor's Licensc [,aw). -l am exempt under Section-, B. & P.C. for this reason. WORKER,S' COMPENSATION DECLARATION I hereby affrrm under penalty of pojury one of the following declarations: / -l havc md will Mintab a Cqtilicate of CotMt to SclfJrouc for workq' compcNdior\ I providcd for by Setion 3700 of thc labor Code. for thc pcfonmcc of thc work for which thc pqmit b issued. ff have and will maintain workcrs' comperuation insurance. as required by Section 3700 of the labor Code. for the petformancc of work this permit is issuod. My workers' compensation insurance cilrier and policy number are: z-/tr/rrI7----7 -l cqtiry that in thc pcrfomancc of thc work for which this pcmit is isued. I shall not cmploy my pmon in my mmna e Gtob@mesubjettothewor*6'composationlawsofcalifomia.mdagcthatiflshouldbeomcsubjcttothc workc'compemtionprcvisiomofSetion3?00ofthet borCodc.ldEll.fonhwith@mplywiththo*prcvisiom. WARNING: Failurc to suc work6' ompcnsaiion ovmge is untawfut, ed shall subjct m qployE to siminal pqEltics sd civil lincs up to ooc hmdrcd thoMd dollm ($100.000). in addition to thc cosi of compcution. &maga u prcvidcd for thc Section 3076 Labor Code. interest and attorncy's fees. DECI.ARATION I hereby affrnn under penalty of pcrjury that I arn licensod under provision of Chapter 9 (cornmencing with Scction 7000) of Division 3 of the Business and Professions Code. and my license is in full force and effect. Number: W I hercby affm unda penalty of perjury that th6e is a @nstruciioo lcnding agocy for thc pqfomucc of the work for which this [mit is issucd (Sa. 3097, Civ. C.). Lmdd's Namc: Lcndcr's Address: APPLICANT DECLARATION I hereb)raffirmunder penalty of perjury one of the following declarations: Demolition Per:rnits-Asbestos Notification Fedcral Regulations (Titlc 40. Part6) _Required Letter of Notification -l coti$r that the federal regulations regarding asbestos removal are not applicable to this projed. F*ifu that I have read this applicarion and state that rhe above infonnation is correct. I agree to comply ordinances and State Laws relating to building construction. and hereby authorize representatives of this City with all City and County and County to e'nter upon the for inspcction Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/Ve nUI ns u latio n Roof Sheathing q lll 4,t 'LrA,ap Shear Wall t \\.,/ Framinq lnsulation/Energy Drwvall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req. Deputy Final Report Enqineer Final Report Flood Zone Certif ,/t FINAL 9/,7bh ,J-fr 1o Certificate of Occupancy (t lv Notes, Remarks, Etc.f \ Date: _ N.rrrr,c, : lrlrc ( I 7 )furoz ,rr", ?h/Z/