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BUILDING- INSPECTOH RECORD SITE-WORK DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION I hcreby affirnl undcr pcnalty of Jrerjury that I am excmpt f@m the Coilmcto6' Liccns taw for thc following rcamn (Sec.7031.5 Busincss and Profcssion Codc): Any City or County which rcquircs a prmit to construcl, alter, improvc, dcmolish or rcpair any struclurc, prior to its issuancc, {lso rcquircs the applicant for such lrcrmit lo filc { signcd statcrcnl thal hc or shc i$ licenscd purslant to thc prcvisions of the Contr8ctor's Liccnsed Law (Chuptcr 9, Cormcrcing with Scction 700O of Division 3 of Ihc Busincss and ProfcssionsCodc)orthathcorshciscxemptthcrcfromBndthcbasisforthcallcgedexcmption. Anyviolationofscction?O3l.5byany applicant for a pcrmit subjtrts thc applicmt to a civil pcnalty of not morc thao fivc hundrcd dollus ($500). -1. as owncr of thc prcFrty, or my cmplo)@s with wagcs as thcir solc comlrcnsarion. will do lhc work ard thc structm is fril ! inlcndcd or olfcred for slc (Sa.7Ol4, Busincss and Pmfessions Codc: Thc Contractor's Liccn* lnw docs not apply to an owncr of thc pmltrty who builds or impmrcs thc@n, and who docs such work himsclf or herself or thrcugh his o. hcr own crnployccs. providcd that such imprcrcmnts re mt intended oroffcrcd for $le. If, howcvcr, thc building or imprcrcmnt is mH wilhinonc ycu of complction, thc Owncr BuiHq will havc the burden of pmving thal hc or shc did mt build or irymvc thc prcFny for thc purporc of sah). -1. as owncr of the propcrty, am exclusively contracting with liccnscd contractors to construct the projcct (Scc. 7W, Busincss and Pncfcssion Codc: The Contractor's License Law does not apply to an owner of property who builds or improves thercon. and who contracts for such projccts with a Contractor(s) liccnsed pursuant to the Contractor's License Law). -IamcxcmptundcrSection-.B.&P'C.forthisreason.Il..r ^. SQB6E8Ii5:OMEENSAIION DECI.ABAIION I hercby affirm undcr pcnalty of pcrjury onc of thc following dcclarations: _l havc iltd will mintair a Ccrtificate of Con$nt to Selflnsurc for workers' compcnsation, as prcvklcd tbr by Section 3?0O of the labor Code, for the performncc ofthc work for which the pcrmit is issucd. Al havc and will maintain workcrs' compensation insurancc, as rcquircd by Section 37OO of the tabor Codc, for the pcrformre of ' Ihc work for which this pcrmit is issucd. My workcrs' ompensalion insurancc cuier md policy numbcr rc: fuluhrnno.rLltrs 0u Policy q lt lzz \Q.l ccniry 'l I that in thc pcrfbrmancc of thc work lbr which this pcrmit is issucd. I shall not cmploy any pcrson in any manner so as to bccornc subject to the workcrs' compensation laws of California, and agrec that if I should bccome subject to the workcrs' compcnsation provisiorrs of Section 3700 of the Labor Code, I shall, tbrthwith comply with those provisions. WARNING: Failure to sccure workcrs' conrpcnsation covcragc is and an crnploycr to criminal pcnaltics and civil lincs up to onc hundrcd thousand dollars ($100,000;,to thc compcnsation. damages as provided for the Section 3076 of the Labor Codc, inlercst and altorncy's I hcrcby allirm undcr penalty of pcrjury that I anr liccnscd undcr provision of Chaptcr 9 (commcncing with Scction 7000) of Division 3 of thc Business and Profcssions Codc, and nry liccnse is in l'ull force and cfl'cct. Liccrrsc zilSb? Dnre: *lt Ll Z Il/ I hercby aflirrn undcr pnalty of pcrjury that thcrc a constructiolr agcncy performancc of the work ltrr which this prmit is issued (Scc. 3097. Civ. C.). Lcndcr's Nanrc: Lrndcr's Addrcss. APPLICANT DECLARATION I hcrcby affinn undcr pcnalty of pcrjury one of thc following declarations: Dcnmlition Permits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40, Part6) _Rcquircd [.ctter of Notification -l ccrtify that thc t'edcral rcgulations regarding asbestos rcmovalarc not applicable to this projcct. that I have rcad this application and state that thc above information is corrcct. I agrcc to comply with all City and County and hcrcby authorize rcprcscntativcs of this City and County to cntcr upon the abovc mcntioned property for Applicant or Agent Permitee nanle 7 Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bf I oo r/Ve nt/l n s u I atio n Roof Sheathinq Shear Wall Framinq lnsulation/Enerqy Drywall Ext./lnt. Lath Brown Coat JMasonry Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif. tl,..t .l F!NAL IU q-t\DWf,'ID' Certificate of Occupancy l\ Notes, Remarks, Etc.