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OWNER BI'II,DER DEI,CARA'I'ION <br />I herctr1 affirm unda pcnalty of peiilry that I m erempt fiom thc Conlracto6' [-icensc l-aw for lhe followin8 rea$n (Sc ?0:11.5 <br />Flusin6s and Profession Code): Any City or Couily which rcquirs a [rcnnit to conslNcl. alts. impreve, dotolish or repair any <br />slnrclue. prior to its isiuance. also reqni.6 the applicanl for such Fmnil to file n si8ncd slalment that hc or shc ie licosed pursuanl <br />lo the prcvisions oflhc Contractor's l,icenwd kiv (Chapts 9. Commencing wilh Scction 7000 ofDivision I ofthe Rusircss and <br />Professions Code) or lhat he or shc is exempt lhsefrem and the heris for the allegcd cxqnp(ion. Any violalion ofsdlion 701 I .5 hy any <br />applicant for a pmit strbjcts the applicant to a civil penalty of not more lhan five hundrcd dollars ($500). <br />l. as o*'ncr of the propelly. ot nry ernployees rvith u,ages as their sole compensation. willdo the u'ork and the stntclure is not <br />inlcntlcd or offered for sale (Sc.c.7044. Business and Professions ('ode: The Contractor's Licensc I.au, does nol apply to an os,ncr of <br />lhe propolv rvho lruilds or irnproves thermn. anct rvho cloes srrch w,ort hirnself'or herself or lhrough his or her ort,n employecs. <br />provitletl that such irnprovenrents are not intencle<l oroffere.cl for sale. I[. hos,ever. the huilding or improve,nent is sold rvithin one ycar <br />o[cornpletion. thc Orvncr Ruilder rvill havc the brrrtlen of proving that he or she did not huild or impror,e the property for the purJxrse of <br />sale). <br />l. as o\\'ner of the propoly. arrr exclusively conlracling s,ith licensed contractors lo conslnrct lhe projecl (Sec. 7044. Brrsrness <br />and Proficssion ('odc: f'he Contractor's l.icense l.arv does not apply to an owner of propmtv s,ho huilds or improves ths'eon. <br />and s'ho conllacls for such projects rvith a Contractor(s) licenscd pursuarrt lo thc Contraclor's l-icense l.arv). <br />_ I arn cxcnrpl urrclcr Section . l]. & l'.('. f<rr llrrs rcason. <br />J)nlt: <br />DECLARA'TION <br />I herehy affirnr uncler penalty of po'jury one oIthe follorving cleclaralions: <br />._--lhaveancls'ill ntaintainaCertificateofConsenttoSelf-lnsureforrvorkers'cornpensation.as providedforbySection.lT00ofthe <br />Lalxrr Code. for lhe perfonnance of the rvort for u,hich lhe po:nit is issuetl. <br />#n:ltl,ili:ir',til;.l"ll;::::L:::'rfiJ,Hil,.I'i'iHJJ;;:J:i:l1;.llri:'J[:ilJhrl'fiJ;ll[l:l' <br />(-arer: htcllll JWlr*l ]pr*,rs* Jolrr/ <br />,",., ;,,f;'uiitr,'t3'ftiFitW - .Exp rc,, -' -04 <br />for the performance of <br />)/ZL <br />_ - I cedify that in the ptrform.f,cc ofthe uork for which this permit is issrerl. I shall not enploy any pcmon in any mnnno <br />so as lo hecornc snliiet to the rvorlios' composation larvs of Califomi.. and agrc that if I should haorne subi(t to I hc <br />rvorkoC compensation provisions ofSstion -17fi) ofthc lalnr Codc. I shall. fo|lhwith comply with those provisions. <br />WARNING: Faihrrc lo sccure workss'conrpensntion covcmge is unlarvful. and shall subjet an qnlloyer to siminf,l lEnlli6 and <br />civil fines up to one h$ndred thousand dollars ($100.000). in addilion lo tlrc cost of compcnsation. damagcs as providcd for the <br />Scclion .1076 of thc l.ahor Coclc. intercst <br />OI <br />Ll(: I,INS lit) (.O N't'RACr'O R <br />Dt!,('LARA'l'l()N <br />I hereby afl'irm under penalty of per.iury that I arn liccnscrl under provision of Chaplo'9 (comrnencing s'ilh Section 7000) of Division .1 <br />of the Busincss and Profcssions Code, and my liccnsc is in full forcc antl elfecl. <br />h Nunrtrcr: <br />L{\5,8L <br />l)n lc: <br />CONS RUC'I'ION LENDTNC ACENC}' <br />I hcrchy aflirm under lmalty of pcrjury thal th@ is I constnrction lending agflcy for tfte pofomance of the rvork for rvhich this gumit is <br />issued (Ss. 30q7. Civ. C.). <br />[,ender's Narne: _ <br />l-ender's Acldress: <br />A PPLICANT DECLARATION <br />I hodry affrnn undt'r poralty of pcr.iury one of the follos,ing cleclarations: <br />Denrolitiorr Pcrrnits-Astrestos Notification Federal Regulations ('title 40. Parl(r) <br />- <br />Required Letterof Notification <br />_ _- I ccrlify lhat lhc fcrlcral regulations regarding asbestos renroval are n()t applicahle to this pro.iect. <br />cor ify I hat I havc read this npplicat ion ancl statc that the ahrve inflormation is corect. I agrcr to cornllly rvith all City and Coqtnly <br />ordinancs f,nd Slate l-aws rclatinE to bililding constnrcl ion. ild herchv authorize rqrscnlal iv6 of this ('ily and (:ounty to ml€ tpon lhc <br />alxrvc lrrcnlionctl propcrly lor <br />l,iccnsc (-lass: <br />,Allplicant or Agent <br />Pcrnrilcc nrlmc <br />-Dn,e:-o Yotf2 t <br />VA <br />SITE-WORK DATE ID/SIG COMMENTS <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />S u bfloor/Ve nUl nsu lation <br />Roof Sheathing <br />Shear Wall <br />Framing <br />Insulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />lMasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />F!NAL <br />Certificate of Occu pancy <br />Notes, Remarks, Etc. <br />BUILDING. INSPECTOR RECORD <br />()rlner: <br />11',0 ItK l,,lts' ('ol\t PI.,NSA l' l()N <br />//