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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DET,CARATION I hqcby affm undq psulty of pcrjury thst I m qmpt ftom thc Coilraclos' Licw kw for the following lwn (SS.7031.5 Busincs ad Profesion Codc): Aoy City or Couty which rcquirc a pcrnit to @Ntrucl, alta, imprcvq dqnolish or Ep8ir uy structuq prior to its issuacc, also rcquirc thc applicet for such pcrmit to filc I signcd starmmt that hr or slE is ticcnscd p6wt to thc prcvisioN of thc Contrrctor's Liccrocd Law (Chaptq 9, Comercing with Setion 7000 of Division 3 of thc Bsine 6d PrcfcsioreCode)orthathcorsheisqcmptthscfrommdthcbssisforthcallcgcdqdprion. Atryviol8tionofSe,tbnT03l.5byey spplicetforapcmitsubjetsthe appliciltloacivilpcnaltyofnotmorcthufivchundrcddollm($500). _1. os owner of the property. or my employecs with wages as their sole compensation. will do the worl< ard the structure is not intended or offcred for sale (Sec.7044, Businas and hofessions Code: The Contractor's Licerse Law does not apply to an owner of thc propoty who builds or improves thcron. and who does such work himself or hersclf or through his or her own employees, providcd that such improvancnts are not intended or offered for sale. lf, however, the building or improvement is sold within onc ycar of compleion, the Orvner Builder will have the hrden of proving tha he or she did not build or improve the propaty for the purposeof sale). _1. 8s owner of thc propcrty, am exclusively contraciing with liccnscd contractors to construct the project (Scc. 7044, Business and Pnofession Code: The Contractor's Liccnse Law does not apply to an owner of property who builds or improves thereon. and who contracts for such projects with a Contracto(s) licaucd pursuant to the Contractor's Liccnsc l-aw). -l am exempt under Scction-, B. & P.C. for this reason. Owner: WORKERS' COMPEIISATION DECI.A]TATION I hcreby affrm under panalty of perjury one of the following declarations: _l have and will maintain a Certificate of Conscnt to Self-lruure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the pcrformance of the work for which the pcrrnit b issued. _l have and will maintain workers' compensation irsurance, as required by Scction 3700 of the Labor Code, for the performance of insurance carrier and policy number are: +*/J.7Lo{-O t Policy _l certi& that in the pcrformance of the work for which this permit is issued, I shall not employ any pcrson in any manner so ils to become subject to the workers' compersation laws of California. and agree that if I should become subjoct to the workcrs' compensation provisions of Section 3700 of the labor Codc, I slull. forthwilh comply with those provisions. WARNING: Failure to secure workers' compensation coverage is unlawful, and and civil fines up to one hundred thousand dollars ($100,000). in addition to the Section 3076 of the Labor Code, interest and attomey's fees. the *Z DECI"ARATION I hereby affrm under penalty of perjury that I am liccnsed undcr provision of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Liccnse c_-aD Number: 6?oO -2[ W I hmby affm utrd6 pcnalty of pcrjury that thsc is a co$truclion lcnding agdcy for thc psfomcc of thc work for which thb pqfiit b Civ. C.). Lender's Address: APPLICANT DECLARATION I herdry affirm under penalty of perjury one of the following declarations: Demolition Permits-Asbcstos Notification Fedcral Regulations (Titlc 40, Pan6) _Required Later of Notification -l certi$z that the lderal regulations rcgarding asbestos rernoval are not applicable to this project. _l ccrti& that I havc read this application and state that the above information is correct. I agrcc to comply with all City and County ordinances and Statc l-aws relaing to building constnrrction"reprcsentatives of this City and County to entcr upon thc abovc mentioned property for purposes. Applicnnt or Agent Ova I'ernritee nanrc (print):fu\Br^t \.B 4-l\:.., ,rr". /0- 1-2J Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/Ve nul ns u latio n Roof Sheathins Shear Wall Framing lnsulation/Energy Drlnruall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif FINAL /o*2.o -21 E--.Q .12 Certificate of Occu pancy Notes, Remarks, Etc.