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\ BUILDING- INSPECTOR RECORD SITE.WORK DATE !D/SIG.COMMENTS Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenUl ns u lation Roof Sheathing Shear Wall Framinq I I lnsulatio nlEnergy I Drywall .l \J Ext./lnt. Lath Brown Coat [\/asonry Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif I I FINAL lolal z b Cefiificate of Occupancv / tL Notes, Remarks, Etc. I hcrcby aflinn under pcnalty of pcrjury that I arn excmpt from the Contractors' Liccnse [,aw for thc 703 r.5 Busincss and Prof'cssion Codc): Any City or County which rcquircs a pcrnrit to construct, altcr, inrprr rcpair any structurc, prior to its issuancc, also rcquires thc applicant for such lrcrrnit to filc a signed statcment thatl .nsed pursuant to thc provisions of the Contractor's Liccnscd Law (Chapter 9, Commencing with Section 7000 of Busincss and PrclbssionsCodc)orthothcorshcisexemptthercfrcmandthebasisfortheallcgcdcxcmption. AnyviolationofscctionT03l.5by"any applicant for a JErmit subjcts thc spplicant to a civil pcnalty of not mrc than live hundrcd dollus ($500). -1. as owner of thc proFrcrty, or nry employecs with wagcs as thcir sole compcnsation. willdo the work and thc stnrcture is not intcndcd or ot'fcrcd for salc (Scc.7044, Business and Profcssions Codc: The Contractor's License Law docs not apply to an owncr of thc propcrly who builds or funprovcs thcrcon, and who does such work himsclf or hcrself or through his or her own cmployccs providcd that such improvcnrnts arc not intendcd or offcrcd fior sah. If, howevcr, the building or improvcnrcnt is sold within onc )rcar of cornplction, thc Owncr Buildcr will have thc burden of proving that he or she did not build or improve the property for thc purpose of sah). _1. as owncr of thc property. am cxclusively contracting with licensed contractors to construct thc projcct (Scc. 7M4, Busincss and Prptcssion Codc: The Contractor's Licensc Law docs not apply to an owner of prolrcrty who builds or improves thcreon. and who contracts for such projccts with a Contractor(s) liccnsed pursuant to thc Contractor's Liccnse t-aw). _l am cxcnrpt undcr B. & P.C. for this rcason. SIIBrEIIITOMPJNSAIIAN DECI.AB{IION I hcrcby aflirm undcr pcmlty of psjury onc of thc following deleations: _lhavcandwill mintainaCcrtifrcateofconscnttoSclf-lnsurcforworkss'compcnsation,&s prcviiedforbySstion3?00ofthe LitDr Cqlc. for thc pcrformncc of thc work for which the permit is issued. [t hvc ana will mintain workcrs' comlrcnsation insurarcc. as rcquircd by Scction 3700 of thc kbor Codc, for lhc 1Erformre of thc work for Carricr: APPLICANT DECLARATION I hcrcby allinn undcr pnalty of perjury onc of thc following declarations: Dcmolition Pcrmits-Asbcstos Notification Fcderal Rcgulations (Titlc 40. Part6) _Requircd lrttcr of Notification _l ccrtily thal thc fcdcralrcgulations rcgarding asbcstos rcmovalare not (-l ccrrify that I havc rcacl this application and state that thc abovc ordinanccs and Statc Laws rclating to building construction. and atxrvc rncntioncd propcrly for Applicant or Agent which this pcrmit is issued. Ilty workers' compensation insurance carrier and plicy numbcr are:rTYurqbvl,l - qKsK e-1 Policy r1 u -l ccrtify that in thc pcrforrnancc of thc work for which this permit is issucd, I shall not cmploy any person inly manner so as to bcconrc subjcci ro rhc workers' compcnsation laws of California, and agrce thar if I should become JUp.t to thc workcrs' comlrcnsation provisions of Section 3700 of the [:bor Code. I shall. forthwith comply with ttnsc provisions. WARNING: Failure to sccure workers' compcnsation covcrage is unlawful. and shall subjcct an cmploycr to criminal ;renalties and civil fincs up to one hundrcd thousand dollars (5100,0001, in addition to the cost of compcnsation. damagcs as providcd for the altorney's DECLARATION I hcrcby alfirnr undcr pnalty of pcrjury that I am liccnscd under provision of Chaptcr 9 (commcncing with Scction 7000) of Division 3 of thc Business and Professions Code. and my license is in full force and a effc.ct.) LLiccnsc Numbcr: W I hcrcby affirm undcr Fn.lty of perjury that thw is a @nstructbn lcnding rgcrcy for thc trcrfol1Mce of thc work for which this pemit is issucd (Scc. 3@7, Civ. C.). kndcr's Namc: lcndcr's Addrcss: 1 Pcntrilce nanre 1 Scction Date:_ ?,o L, lrr^"rNQ c'