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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hrcby affm undo pmaky of pe'jury that I m cxempt from thc Contracton' Licw Law for the following reun (Se.7031.5 . BsitrBs and Prof6sion Codâ‚¬): Any City or County which require a pamit to oNtruct. altc, improvc, doolish or rqai ay structure. prior to its issuocc, also rrcquirc thc applicmt for such pemit to file a signed statemmt that hc or shc b licGcd pmumt to the prcvisioE of thc Contractor's Licenscd Law (Chaptq 9, Comencing with Setion 7000 of Division 3 of thc Buinss md Prcfesions Code) or that he or she is exmpt thqefrom md the b6is for the allcgcd exmption. Any violation of Sslion 7031.5 by ey - applicilt for a pmit subjets the applicant to a civil pmalty of not more thm five hundred dotlus ($500). _1, as owner of the propeny. or my employees with wages as their sole compensation, will do the work and the structure is not intended or offered 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 thâ‚¬reon, and who does such work himself or herself or through his or her own employees. provided that such irnprovernents are not intended or offered for sale. If, however, the building or improvement is sold within one ye{r of cornplaion, the Orvner Builder will have the burden of proving that he or she did not build or improve the property for the purposeof sale). -1, as owner of the propeny, am exclusively contracting with licensed contractors to construct the project (Sec. 7U4, Business and Profession Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a Contractor(s) licensed pursuant to the Contractor's License Law). _l arn exempt under B. & P.C. for this reason. O*ner: WORKERS' COMPENSAT DECLARATION I hereby afhrm under penalty of perjury one ofthe following declarations: -l have and will maintain a Certifrcate of Consent to Self-lnsure for workers' compexsation, as provided for by Section 3700 of the Labpr Code. for the performance ofthe work for which the parnit is issued. J n^u"and will rnaintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this pennit is My worters' compensation insurance carrier and policy number are: Policy LL _l certi& that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so as to bccome subject to the workers'comperuation laws of California, and agree that if I should become subject to the rvorkers' 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 anployer to criminal penalties and civil fines up to one hundred in addition to the cost of compensation. darnages as provided for the Section 3076 of the interest f,ees. a i ( DECLARATION I hereby affrnn under penalty of perjury that I am 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 Nurnber:tl I + CONSTRUCTION LENDINC AGENCY I hâ‚¬rcby affrm undtr penatty of perjury that thse is a comtruction lmding ag@cy for the pqformce of the work for which this p6mit is issued (Str. 3097, Civ. C.). Lender's Name: Lender's Address: APPLICANT DECLARATION I hoeby affu:n under poralty of perjury one of the following declarations: Demolition Perrnits-Asbestos Notification Federal Regulations (Title 40, Part6) -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 information is correct. I agree to comply with all City and County ordinances and State Laws relating to constructron, and hereby authorize representatives of this City and County to entâ‚¬r upon the above rnentioned prope(y for o9Applicant or Agent fij ttldu) [u lf t4 Pernritee nanle 0l Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloo r/VenUl nsu Iation Roof Sheathinq Shear Wall Framing Insulation/Enerqy Drnrvall Ext./lnt. Lath Brown Coat N4asonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif FINAL Certificate of Occupancy Notes, Remarks, Etc. I