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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION I hreby affirm unda pcnalty of pojury that I m qempt from thc CootractoB' Licme lrw for thc following rcNn (Se.7031.5 Businss md Prcfcsion Code): Any City or Couily which rcquira a po'rnit to coNtruct. alt6, improvq dsnolish or rcpair ily structuq prior to its issuoce. also requirs the applic@t for such pcmit to filc a signcd stalmot rha hc or shc b licosed pmwt to thc provisioN of the Contractor's Licmscd taw (Chaprq 9. Commmcing with Setion 7000 of Division 3 of thc Buins ad PrcfsionsCode)orthathcorshciscxcmptthqcfromudthcbGsisforthcallegcdexmption. AnyviolationofSdbnT0Sl.5byany applicantforapmitsubjatsthc applicanttoacivilpcnaltyofnotmorcthufivchundrrcddollm($500). _1. as owner of the property. or my employees with wages as their solc compcnsation. will do the work and the structure is not intended or offered for sale (Sec.7044. Business and hofessions Code: The Contractor's License law docs not apply to an owner of the property who builds or improves thcron, and who does such work himself or hersclf or through his or hcr own employees, provided that such improvanents ile not intended or offcrod for sale. If. howevcr, the building or improvernent is sold within onc )â‚¬ar of completion, the Owner Builder will have the b,urden of proving that he or she did not build or irnprove thc propoty for the purposeof sale). _1. as owner of thc propcrty. am exclusivcly contracting with licensed contractors to construcl the project (Sec. 7044. Bwiness and Prrofession Code: Thc Contractor's License Law does not apply to an owner of property who builds or improves thereon. and who contracts for such projects with a Contracto(s) licensed pursuant to the Contractor's License l-aw). _l am exempt under Section_. B. & P.C. for this reason. Date: I hercby affirm under penalty of perjury one ofthe following _l have and will rnaintain a Certificate of Consent to Self-lnsure for rvorkers' compeirsation. as providcd for by Section 3700 of the Labor Code. for the perfonnance of the work for which the pcrrnit is issued. _l have and will rnaintain workers' compensation insurancc. as by Section 3700 of the Labor Code, for the perfonnance of the work for this pennit carrier and policy number are: a a wPolicy -l ccrri$ that in the pcrformance of the work for which this permit is issued, I shall not onploy any pcrson in any manner so as to become subject to the rvorters'compensation laws of California. and agree that if I should become subject to the workers' compensation provisions of Scction 3700 of the Labor Code, I shall. forrhwith comply with those provisions. WARNING: Failure to sccure workers' compersation coverage is unlawful. and shall subjcct an onployer to oiminal penaltics and civil fincs up to one hundred thousand dollars ($100.000). in addition to the cost of compensation, damages as provided for the Section 3076 of the Labor Code, interest and attorney's fees. ,^,", -07//ql21 , DECI"ARATION I hereby affrrm under penalty of perjury that I am licensed under provision of Chapter 9 (comrnencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. , License ,?Nurnbcr:o 2 q,qt?D a erv I L r Ola W I hrcby affm unda pclalty of pqjury that thqâ‚¬ is a consrruction lmding agqcy for thc pqforrmcc of thc work for which this pqmit b issucd (Se. 3097, Civ. C.). kndd's Nmc: Lender's Address: APPLICANT DECLAIIATION I hereby affrnn under penalty of perjury one of the following declarations: Dernolition Permits-Asbcstos Notification Federal Regulations (Title 40. Par16) _Required Lrtter of Notifrcation above mentioned properry for Applicant or Agent Pernritee CL ,^," rb\Iq/? I Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloor/Ve nUl n s u Iatio n Roof Sheathing Shear Wall Framing lnsulation/Energy lo -2,o -2-l Bt*4z Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Fina! Report Flood Zone Certif FINAL I o- Zo-2t EEr*tlz Certificate of Occupancy Notes, Remarks, Etc.