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BUILDING. INSPECTOR RECORD SITE-WORK DATE ID/SIG,COMMENTS Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/Ve nUI n s u Iatio n Roof Sheathing Shear Wall Framing Insulation/Energy Drlnrvall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif FINAL Certificate of Occupancy Notes, Remarks, Etc. OWNER BUILDER DELCARATION I hacby affrm undr pemlty of perjury that I m qcmpt ftom thc Contretos' Liccre Llw for thc following remn (Se.7031.5 Busins md Profsion Code): Any City or County which rcquire a permit to corotruct, altq, improvq drxnolish or rcpai uy structuq prior to its isumca also requirG thc applicml for such pflnit to filc a signcd stat@ot that hc or she is licosed pmuat to rhe p@visiom of the Contractor's Liccnscd Law (Chaptq 9, Commcing wilh Sation 7000 of Division 3 of thc Buire ad' Prcfcsions Code) or that he or shc is cxempt thcefrom md thc bosis for the allcgcd cxstrption. Any violation ofs6{ion 703 1.5 by dy applicantforapcmitsubjctsthc applicmttoacivilpenaltyofnotmorcthilfivchundreddollrs($500). _1. as owner of the property, or my employees with wages as their sole compansation. willdo the work and the structure is not intcnded or offered for sale (Sec.7M4. Business and Professions Code: The Contractor's License Law does not apply to an owner of the property who btrilds or Lnproves thcreon. and who does such wort himself or herself or through his or her own employees. provided that such improvanents are not intended or offered for sale. If, horver/er. the building or improvement is sold within one year of cornplaioru the Or*,ner Builder will have the hrden of proving tha he or she did not build or impirove the propoty for the purpose of sale). -1, as owner of the propefty, am exclusivcly contracting with licensed contractors to construct the project (Sec. 7M4, Business and hofcssion Code: The Contractor's License Law does not apply to an owner of property who builds or irnproves thereon, and who contracts for such projects with a Contractor(s) licerse<l pursuant to the Contractor's Liccnse Law). -l arn exempt under Section-, B. & P.C. for this rcason. WORKERS' COMPEI{SATION DECLARATION I hereby affirm undcr penalty of perjury one ofthe following declarations: _l have and will maintain a Certificate of Consent to Self-lnsure for workers' cornpensation. as provided for by Section -3700 of the L"bo, Code. V/nur" una for the pcrformance of the work for which the perrnit is issued. will maintain workers' compensation insurancc, as required by Section 3700 of the Labor Codc. for the perfonnancc of which this permit is issued. My workers' compensation insurance carrier and policy number are:thc work e A Policy _l cefliry that in thc psfonmncc of thc work for which this pcrrnit is issucd. I shall not mploy any pâ‚¬rsn in sy munq $ 6tobsomesubjettothewort6'compensationlawsofCalifomia,mdagrethatiflslDuldb$omcsubjsttothc workm' compensalion provisiore of Sction 3700 of the kbor Code, I slull, fonhwith comply with thos prcvisions. WARNING: Failurc to suc wrkm' compcosation covcr.Sc is unlawful, md shall subjct e oployd to qimhal psultiB md civil fins up to onc hun&cd thoMd dollG ($100,000). in addition to the cost of @mp6retion. daragB 6 povidcd for thc Section 3076 Labor Code. interest and attorney's fees. DECI.ARATION I hoeby aflirm under pcnalty of perjury that I am licensed under provision of Chapter 9 (commencing with Seoion 7000) of Division 3 of the Business and Professions Code. and rny license is in full force and effect. License Nurnber:;E c J{ W I hmby affum undo pcnalty of pqjury that th@ is a comtruclion lmding agocy for thc pqformcc of thc wrk for which this pqmit b issucd (Sw. 3097, Civ. C.). Lender's Name: Lcnder's Address: APPLICANT DECLARATION I hcrrby affunn under penalty of perjury one of the following declarations: Demolition Permils-Asbestos Notification Federal Regulations (Title 40. Part6) -Recluired Letter of Notification _l certifu that the federalregulations regarding asbestos removal are not applicable to this project. 4d, ccrtifo that I have read this application and state that the above information is correct. I agree to comply with all City and Counry ordinances and State Laws relating to building hereby authorize represefltatives of this City and County to enter upon the above mentioned property for inspec'tion purposes. Applican( or Agent Pcrmilce I Expires:t* r ?t )rr