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BU!LDING- INSPECTOR RECORD SITE.WORK DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION I hacby affrm unde penalty of perjury thar I m cxcmpt fiom thc Contracton' Licw Law for thc following rwn (Se.7031.5 - Buinss od hofesion Codc): Any City or County which rcquirc a pornit to @Etruc{, alto, improvc, dmolish or rcpair my. structuc. prior to its isumce. also rcqut6 thc applicet for such pennit to lilc a signcd statm@t that hâ‚¬ or srtc b lic@scd ptMt. to thc provisioN of thc Contrrctor's Licmscd taw (Chapto 9, Comcncing with Setion 7000 of Division 3 of the Busines ud Prcfsiom Codc) or that hc or she is exmpt thaefrom ad thc b6sis for thc allcgcd cxmgion. Any violation of Sction 7031.5 b) oy applicmtforapmitsubjwtsthc applicmttoacivilpcmltyofnotmorcthilfivehundrcddollus($500). t' --1. as owner of the propcrty. or my employeâ‚¬s with wages as their sole compcnsation. willdo the work and the stnrcture is not intcndod or offerd for sale (Sec.7044. Business and hofessions Code: The Contractor's License Law does not apply to an owner of the property who builds or improves theron. and who does such work himself or hcrself or lhrough his or her own employees, provided that such improvanents arc not intended or offâ‚¬red for sale. l[, howerrer, the building or improvement is sold within one ]rar of completion. the Orvner Builder will have the hrden of proving thd he or she did not build or improve the property for the purpose of sale). _1, as owner of the property, arn exclusively contracting with licerued contractors to construct thc project (Sec. 7U4, Business and Professbn Code: The Contractor's Liccnse Law does not apply to an ownef, of property who builds or improves thereon. and who contracts for such projects with a Contraclor(s) licersed pursuant to the Contraclor's Liccnse l-aw). -l am exempt under Section-. B. & P.C. for this reason. h.r, a.ffi I hercby affirm unde penalty of po'jury one of thc following delratioN: / -l have and will maintah a Certifrcstc of CoMt to Sclf-lmurc for workc' comFnsation, r providld for by Sction 3700 of thc L0bor Codc for thc psfommcc of the wrt for which thc pmit is isued. %"" "na *itt r"inr"in *o.t *' .o.p"Eation imumcq I rcquircd by sstion 3?00 of thc Lrbor codc, for thâ‚¬ pcfoImcc of -rhc work for which this pqmit is ised. My worko' ompasaion irourmic cmiq ard policy oumba rc: uno 12-l-z/ __l cari$ that in the perforrnance of the work for which this perrnit is issued, I shall not employ any person in any manner so ils 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. forthwith comply with those provisions. WARNING: Failure to secure workers' compensation coverage is unlawful, and shall subject an employer 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 3076 of the Labor Code, interest and attorney's fees.Ar^&8,-3i - zi I hereby affrrn under pcnalty of perjury that I am licensod 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code. and my license is in full force and effect. Nurnber:7L/7b 3 ,'i/,en W I hercby affm und6 penalty of pcrjury that thqe is a corotruaion lcnding agacy for thc pqfomucc of thc work for which this pqmit b issucd (Sc. 3097, Civ. C.). Lender's Name: l-ender's Ad&css: APPLICANT DECLARATION I hoeby affrrn under penalty of perjury one of the following dcclarations: Dernolition Permits-Asbestos Notification Federal Regulations (Titlc 40. Part6) -Required Letter of Notification _l certi& that thc federal regulations regarding asbestos removalare not applicable to this project. W*ifu that I have read this application and statc that the above infonnation is correct. I agrec 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 â‚¬nter upon the above mentiond property for inspection Applicnnt or Agent I Permitee name I oarc, 8-31'21 Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloor/VenUl n su latio n ,l ,-._ Roof Sheathing q li lt,\J '37 ) Shear Wall \rr7 Framing lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence ,/ T-Bar \ Handicap Req. Deputv Final Report Enqineer Final Report Flood Zone Certif. /l .-- FINAL L ,LJ iail Certificate of Occupancy ' I Notes, Remarks, Etc. / \ a