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BUILDING. INSPECTOR RECORD SITE-WORK DATE ID/S!G.COMMENTS OWNER BUILDER DELCARATTON I hseby a{Iirrn undo pcmlty of pcrjury thal I m cxmpt from thc Contractos' Licmc law for thc following twn (SG.7031.5 Buins od Profsion Code): Any City or County which rcqut6 a pqmit lo comtruct, alt6. improvq dsnolish or rcpair'uy structuq pdor to its isumce. also requirG thâ‚¬ applicilt for such pcrmit to filc a signcd statmot thrt hc or strc b liccnscd ptNlt to the provisions of tlrc Contrrctor's Liccnscd llw (Chaptq 9. Comocing with Setion 7000 of Division 3 of thc Busins ed PrcfesionsCodc)orthathcorshâ‚¬isexmptthqcftommdthcbasisforthcallegcdexmption. AnyviolationofSetionT03l.5byany applicantforapemitsubjetsthe applimttoacivilpcmltyofnotmorcthulivehundreddollm($500). -1. as owner of the property, or my employees with wages as their sole compensation. will do the work and the structure is not intended 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 docs such work himself or herself or through his or her own employees, provided that such improvernents arc not intended or offered for sale. lf. however. thc building or impnovement is sold within one ]tzr of completion. the Orvner Builder will have the burden of proving that he or she did not build or irnprove the propoty for the purpose of sale). -1. as owner of the property, am exclusively contracling with licersed contraclors to construct the project (Sec. 7U4, Business and Profâ‚¬ssion Code: Thc Contractor's License Law does not apply to an owner of property who builds or improves thereon. and who contracls for such projects with a Contraclo(s) licaued pursuant to the Contractor's License Law). -l am exempt under Section-. B. & P.C. for this reason. f)rto. WORKERS' COMPENSATION DECLARATION I hereby affrrm under penalty of po'jury one of the following declarations: -l have and will maintain a Certificate of Consent to Self-lnsure for workers' compcnsation! as provided for by Section 3700 of the labor Code.for the performance of the work for which the pâ‚¬nnit is issued. will maintain workers' comperuation insurance, as required by Scction 3700 of the l-abor Code, for the performance of which this permit is issuod. My workers' compeflsation insurance carrier and policy number are:I have and t\- rc o C. \1(74 Glt lzz Jt certify that in the performance of the work for which this permit is issued, I shall not ---r--T- employ any person in any manner so as to become subject to the workers' compensation laws of California. and agrce that if I should become subject to the rvorkers' cotnpensation provisions of Section 3700 of the Labor Code. I shall. fonhwith comply with thosc provisions. WARNTNG: Failure to secure workers' compcnsation coverage is unlawful. and shall subje<t an onployer to criminal penalties and civil fines up to one hundred thousand dollars ($100.000). in addition to the cost of compensation, damages as provided for the I Soction 3015 of the t hr Code, Dare: Y 113[ Z, interest and attorney's fees. Atcq$lov.â‚¬-\r DI,,('t.AILt't'l()N I hoeby aflirm under penalty of perjury that I arn licensed under provision of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License L'lo Number: q W t hrcby affim undo pcnalty of pcrjury thar fte is a @ns(ruction loding agmcy for thc pqfomucc of thc wrk for which this pqnit b isucd (Sc. 3097, Civ. C.). [rndq's Namc: knder's Address: APPLICANT DECLARATION I hereby affinn under penalty of perjury one of the following declarations: Dernolition Perrnits-Asbestos Notification Federal Regulations (Title 40. Pan6) -Required Letter of Notification -l certi& that the federal regulations regarding asbestos removal are not applicable to this project. _l certi& that I have read this application and state that the above infonnation is correct. I agrec to comply with all City and County ordinances and State laws relating to building of this City and County to ent6 upon the above mentioned property for inspection Applicant or Agent Pernritee nanre v and hereby authorize represertatives 1- Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloor/VenUl ns u latio n Roof Sheathinq Shear Wal! Framing lnsulation/Enerqy Drynruall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif. lt FINAL Qltsla,,JAzn Certificate of Occu Notes, Remarks, Etc.I Owner: Date:_