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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hreby affirm unda pcnalty of pcrjury that I m cxcmpt from thc Contr&toa' Liccmc Law for thc following rcen (Ss.7031.5 Bwinas ad Profxion Code): Any city or County which rcquim a pcmit to costruct. altq. inprove &molish or rcpair ay structuq prior to its isuocc, also rrquiro thc applicmt for such pcrmit to filc a signed stsrflmt that hc or dE is licasâ‚¬d pwuut to thc p(ovisioG of thc Contrrctor's Liccnsed law (Chaptd 9, Commcncing with Setion 7000 of Divbion 3 of thc Buincs ud Prcfsions Codc) or that hc or shc is exmpr thqefrom od thc basis for the allcScd exmFion. Atry violation of Se{ion 7031.5 by ey applicutforapcrrnitsubjetsthe applicanttoacivilpcmltyofnotmorcthefivchundrcddo[as($500). _1, as owner of the properly. or my employecs with wages as their sole compensation, willdo the wort and the structure is not intended or offered for sale (Sec.7044. Business and hofessions Code: The Contractor's License Law does not apply to an owner of the property who builds or improvcs thereon. and who does such work himself or herself or through his or her own employecs, provided that such improvonents are not intended or offered for salc. If, howerrer. the building or improvemcnt is sold within onc )tar of completion" the Orvner Builder will have the burden of proving that he or she did not build or improvc tlte ptopetty for the purposeof sale). _1, as owner of the property. am exclusively contracting with licensed contractors to construct the projcct (Scc. 7M4, Business and hoftssion Code: The 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) liccrsed pursuant to the Contractor's License Law). -l am exempt under Scction-. B. & P.C. for this reason. WORKERS' COMPENSATION DECLARATTON I hereby affrrm under penalty of perjury one of the following dc,clarations: _l have and will maintain a Certificate of Consent to Sclf-lnsure for workers' compensation, as provided for by Section 3700 of thc Labor Code. for the performance of the work for which the perrnit is issued. _l have and will maintain workers' compensation insurancc. ils rcquired by Section 3700 of the t-abor Code, for thc performance of the work for which this pennit is issued. My workers' compensation insurance carricr and policy number are: tngvn^nk FuruD Policy 5*l-zZ _l certi& that in the performance of the work for which this permit is issued, I shall not employ any person in any manner t so as to becomc subject to the workâ‚¬rs'compersation laws of California, and agree that if I should become subject to the provisions of Section 3700 of the L^abor Code, I shall. forthwith comply with thosc provisions.workers' compcnsation WARNING: Failure to sccure workers' compensation coverage is unlawful. and shall subject an onploycr to criminal Sranahies and compensation. damages as plovided for thecivil fines to one hundred thousand dollars ($100,000), in addition to the cost of Section Labor Code, interest and attorney's -Zl I hereby affirm under penalty of perjury that I am licensed under 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. ? C3 Nurnbcr: q{6 167 6-7 tbc W I h@by affum undq pcnalty of pcrjury that th@ is a consructbn knding agocy for thc pofommcc of thc wrk for which this pqmit is issued (56. 3097, Civ. C.). Lender's Name: Lender's Address: APPLICANT DECLARATION I hodry alnrm under penalty of pcrjury one of the following declarations: Demolition Permits-Asbestos Notification Federal Regulations (Title 40, Part6) -Required Letter of Notificdion\ --l certiff that the federal regulations rcgarding asbestos rernoval are not applicablc to this project. _l certify that I have read this application and state that the above infonnation is correct. I agree to cornply with all City and County ordinances and State laws rclating to building construction,representatives of this City and County to c{ter upon the above mentioned property for Applicant or Agent Pcrmitec nRme II l)ql o' g - l1-z( Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/Ve nUl ns u latio n ,l Roof Sheathing IJII,trtv Shear Wall Framing lnsulation/Enerqy Drvwall Ext./lnt. Lath Brown Coat Jvlasonry Pool Fence T-Bar Handicap Req Deputv Final Report Enqineer Final Report Flood Zone Certif ,I I , F!NAL ?l'uru yr{w67 Certificate of Occupancy Notes, Remarks, Etc.