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BUILDING- INSPECTOR RECORD SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcreby aflrnr undcr Fnalty of pcrjury thlt I .m cxer{rl fmm llE Contrrcto6' Licen* [aw for thc following wn (Sec.7031.5 Busincss and Pmfcssion Codc): Any City or Counly which rcquircs r tEmit lo conslruct. olter, ir{rrcve, &mllsh or rcpir my struture, prior lo its issuilcc, also rcquircs thc applicant for such [rcrmit to filc a $igncd statcrcnl that hc or shc is liensd puEumt to lhc prcvisions of lhc Contractor's Liccnmd Lrw (Chaplcr 9. Commncing with SNlion 7000 of Division 3 of lhc Busircss md PrcfcssionsCode)orthathcorsheisexctrptlhcrcfmmondthcb&sisforlhcslhgcdcxcmption. AnyviolstionofSrctbnT03l.5byany applicanl for a pcrmil subjcts thc applic8nt to a civil pcruIy of not morc thil fivc hurdrcd dolltrs ($500). C _1. as owtrcr of the propcrty, or my cmployccs with wagcs as thcir solc compcnsation. willdo thc work and the stnrcture is rnt intended or offered for sale (Scrc.704a. Busincss and hofcssions Code: Thc Contraclor's Liccnse [:w docs not apply to an owner of the proprty who builds or improvcs thcrcon. and whcr docs such work himself or hcrself or through his or hcr own employecs, providcd that such impovcnrcnts arc not intendcd or offcrcd for sale. lf, howcrar. thc buiHing or ir1)roventnt is sold wilhin one )rcar of complctiorL thc Owner Buildcr will havc thc burdcn of proving that he or she did not build or inrprovc the proprty for thc purprse of salc). _1. as owner of thc propcrty. am cxclusively contracting with liccnsed conlraclors lo conslruct thc projcrt (Scc. 7U4, Busiltcss and Profcsskm Codc: Thc Contractor's License Law docs not apply lo an owncr of propcrty who builds or improves lhcreon, and who contracts for such gnojcos with a Conlractor(s) liccnsed pursuant to thc Contractor's Liccnse [:w). _l am cxcnrpt undcr Scttion-, B. & P.C. for thls rcason. Dale:,Owner:_ WORKERS' COM PF'NSATION D['CI ARAflON I hcrcby affirm undcr Jrcnalty of pcrjury onc of thc following dc.clarations: _l have and will maintain a Ccrtifrcate of Conscnt to Sclf-lnsurc for workcrs' comlrcnsation. as provided for by Scrction 3700 of the Codc. for the pcrformancc of thc work for which the permit is issucd. and will maintain workers' comlrcnsation insurance. as rcquircd by Section 3700 of the labor Codc. for the performarrce of which this issucd. My workcrs' compensation insurancc carricr ard plicy numbcr arc: Q4PolicyIo _l certify that in thc pcrformancc of thc work for which this permit is issued. I shall not employ any pcrson in any manner so as to bcconre subject to the workcrs' compcnsation laws of Califomia, and agrcc that if I should beconrc subjcct to ttp workcrs' comgrcnsation provisions of Section 3700 of the l-atnr Codc, I shall, forthwith comply with those pmvisions. WARNING: Failurc to sccurc workcrs' compensation covcrage is unlawful. and shall subject an rmployer to criminal pcnalties and civil fincs up to onc hundrcd thousand dollars ($100.000). in addition lo thc cost of compcnsation. damages as providcd for the Scctiorr of I,atnr Codc, intcrcst and attorncy's l)atc:T0)n Applicant: t)tict ,\t(,\'l'loN I hercby affirrn under pcnalty of perjury that I am licenscd undcr provision of Chaptcr 9 (comrrrcncing with Section 7000) of Division 3 of thc Business and Professions Codc, and my licensc is in full lbrce and effect. Liccnsc Nunrber:t(to{ W I hcrcby affirm urder lEnalty of Frjury Ihat thm is a onstruction lcnding agcncy for thc JrcrforlMcc of thc work for which this Frmit is issued (Scc. 309?, Civ. C.). lrndcr's Nartrc: lrnder's Address: APPLICANT DECLARATION I hcrcby allirnr under pcnalty of pcrjury onc o[ thc following dcclarations: Dcmolition Pcrmits-Asbcstos Notification Fcdcral Rcgulations (Title 40. Part6) _Rcquircd [rtter of Notification Applicant or Agent Pernritee nunle u2o Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenYI nsu latio n Roof Sheathinq Shear Wall Framing Insulatio nlEnergy Drvwall Ext./lnt. Lath Brown Coat Nlasonry Pool Fence T-Bar ( Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif FINAL Certificate of Occupancv Notes, Remarks, Etc. Rev. 08'07-201 5 ( tA