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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG,COMMENTS Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenVl nsu I ation Roof Sheathing Shear Wall Framing Insu Iation/Enerqy Drywall Ext./lnt. Lath Brown Coat lVlasonry Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif FINAL Certificate of Occupancy Notes, Remarks, Etc OWNER BU I LDER DELCARA'I'ION I hereby affirm under penalty of Jrerjury that I am exempt from the Cuntractors' License Law for the following reason (Sec.70.11,5 Business and Profession Code): Any City or County which requires a permit to construct. alter, improve. dennlish or repair any structure. prior to ils issuance. also requires the applicant frrr such permit to file a signed statement that he or she is licensed pursuant to the prcviskrns of the Contraclor's Licensed Law (Chapter 9. Commencing with Section 7(XD of Division 3 of the Business and PmfessionsCode)orthatheorsheisexempttherefromandthehasisfortheallegedexemption. AnyviolationofSectionTO.ll.5hyany applicant for a yrcrmit suhjects the applicant to a civil penalty of not rnore than five hundred <Iollars ($5m). -1. as owner of the property. or my empkryees with wages as their vrle compensation. will do the work and the stru,cture ls not interxled or offeretl for sale (Sec.7O44. Business and hofessions Code: The Contractor's License Law does not apply to an owner of the property wlxl huiltls or inrpnrves thereon. an<l whl dtrs such work himself or herself or through his or her own emphyees. provided that such improverrnts are not intended ur offeretl ftrr sah. If. hlwever, the huilding or inpnrvenrnt is sokl wihin one )rar of completion. the Owner BuiUer will have the hurden of pnrving that he or she did rxrt build or improve tlrc fnof,erty forthc purprseof sah). -1. asownerof theproperty. amexclusivelycontracting with licensed contractorstoconstruct the pmject (Sec.7044. Business antl Pnrfessirn Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon. and who contracts for such pnrjects with a Contracto(s) licensed pursuant to the Contractor's License Law). -l amexempt under Section_. B. & P.C. for this reason. l)ate: ( )rvnrr: WORKE,RS' COMPENSAI'ION DE,CLARATION I herehy affirm under penalty of perjury one of the following declarations: -lhaveandwill maintainaCertificateofConsentto.Self-lnsureftrrworkers'compensation,as providedforbySection3T(X)ofthe Labor Code, for the perfrrrmance of the work for which the permit is issuetl. 1fi norrand will maintain workers' compensarion insurance. as required hy .Section 37fi) of the Lahor Code, for the performance of - the work for which this permit is issgetl. My wrlrkers' compensation insurance carrier and plicy number are: ,*,*,,7,,1 bA (b(/:,Cfum , WWI ,4qF5.-a?- A(,'rt/zLoPolicy Number: l -l certify that in the performance <lf the work for which this Jrcrmit is issued. I shall not employ any Frcrson in any manner so as to beconr suhject to the workers' compensalion laws of California. and agrce that if I should become subject to the workers' compensation provisions of Section 37(X) of the lahor Code. I shall. forthwith comply with those provisions. IVARNING: Failure to secure workers' colnpc'nsntion coverage is and shall subject an enrployer to criminal Jrenalties and civil fines up to one hundred thousantl tftrllars ($1ffi.(XX)). in <lamages as provided for the Section .1076 of the Lahrr Crxle. interest antl Lt/'2222 I I hereby affirm untler penalty of Jrerjury that I am 9 (comrrncing with Section 7(XX)) of l)ivision .l of the Business and hofessions Co<le. and my license is in full frrrce and effect. eetP'rLLT6 License 2 ?u Lo I hereby affirm under penalty of per.iury that issued (Sec. 3O97. Civ. C.). tsa lending agency firr the perftrrmance of the work frrr which this prmit is l-entler's Name: Lender's Address: APIDI ICAN'T DECLARA'I'ION I hereby affnm under penalty of perjury rrne of the following tleclarations: Denxrlition Permits-Ashestos Notification Federal Regulations (Title 40, Part6) -Required Letter of Notifrcation regulations rcganling asbes(os removalare not applicahle trr this project. application anrl the ahrve infirrrntion with all City antl County and County t0 enter u;xrn the ahlve rnentionetl Applicant or Agent Permitee name ttl CL l.?6 $kx *,", I f ztf?PIA Flev. 08-07-201 c()st t (pnnt):-------Z