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BUILDING. INSPECTOR RECORD SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcrcby affirm undcr penalty of pcrjury that I m cxcmpt fmm the Contractors' Licens law for thc following rca$n (Scc.7031.5 Busincss and Protbssion Codc): Any Cily or County whhh rcquircs a lrcrmit to construct, altcr, inprcre, dcmlish or rcpair any slruclurc. friol to its issuoncc, als rcquircs the applicatrl for such pcrmil to filc a signcd statcmnt that he or she is liccnsd pursant lo thc provisiotrs of thc Contractor's Liccnscd l:w (Chaplcr 9, Comcrcing with Sation 7000 of Division 3 of thc Business and Prcfcssions Codc) or that he or shc is cxcmpt thwfrom and thc basis for thc alhgcd cxemption. Any violation of Setion 7031.5 by any applicant for ! pcrmit subjsls lhc {pplicanl lo ! civil pcmhy of not mrc than fivc hundrcd dollus ($500). -1. as owncr of the propcrty, or my employees with wagcs as thcir solc compcnsation, willdo thc work and thc stnrture is not intcndcd or olfcred for salc (Sec.7(X4, Business and Prot'cssions Codc: The Contractor's Liccnsc law docs not apply to an owncr of the propcrty who builds or impmvcs thcrcon. and who dcrcs such work himsclf or hcrself or through his or hcr own employccs, providcd that such improvenrcnts arc not intcndcd or offcred for salc. If. howcver. thc building or improvcnEnt is sold within onc )car of cornplction, the Owner Buildcr will havc thc burdcn of proving that he or shc did not build or irnprovc thc property fbr thc purlnscof salc). -1, as owncr of thc propcrty, anr cxclusivcly contracting with liccnscd conlractors to construct thc projcct (Scc. 7044, Busincss and ['tofession Codc: Thc Contractor's Liccnsc Law docs not apply to an owncr of property who builds or improvcs thcreon, and who contracls for such projccts with a Contraclo(s) liccnscd pursuant to thc Conlraclor's Licensc [:w). -lantcxettlptunderScction-'B.&P.C.forlhisrcason. Owner' wtr qxn ts' corna pn'Nsll rlt rx DECLARATION I hcrcby affirnr under pnalty of pcrjury onc of thc following dcclarations: -l havc and will maintain a Ccrtificatc of Conscnt to Sclf-lnsurc for workcrs' compcnsation, as providcd for by Scction 3700 of the l-ltnr Codc. lbr thc prcrformancc of thc work for which the pcrrnit is issucd. -l havc and will maintain workcrs' compcnsation insurancc. as rcquircd by Scction 3700 of the Labor Codc, for thc pcrformance of thc work for which this pcrmit is issued. My workcrs' com[rcnsation insurance carrier and plicy numbcr arc: lzzvLtl'olicy -l ccrtify that in thc pcrfornmncc of thc work for rvhich this pcrrnit is issucd. I shall not ",rn,nr{n, I pcrson in any manncr so as to bccorrrc subjcct to the workcrs' compcnsation laws of California, and agrcc that if I should beconrc subjcct lo lhc workcrs' conrpcnsation provisions of Section 3700 of thc L:bor Code. I shall, forthwith comply with thosc provisions. , WARNING: Failurc to sccure workers'comlrcnsation covcragc is unlawful. and shall subjcct an crnploycr to criminal pcnaltics and civil lincs up to one hundred thousand dollars ($100.000), in addition lo thc cost of compensation, damages as providcd for thc Scction 3076 of thc Lahrr Codc. intcrcst and attonrcy's fccs. oR/ oQ lztI)nh:'l I I hcrcby aftirnr undcr pcnalty of perjury that I am liccnscd undcr provision 9 (comnrcncing with of Division 3 of thc Busincss and Prol'cssiorts Code, urd my license is in full force and cttect. .l Nurnbcr:"4Liccnse Date:/ nRloq /zr c W I hcrcby affirm under Fnalty of JErjury that therc is a construction lcnding rycrcy for thc pcrformncc of thc work for which this permit is issucd (Sec. 3097, Civ. C.). Lrndcr's Nanrc: [,cndcr's Addrcss: APPLICANT DECLARATION I hercby aft-rnr undcr penalty of pcrjury one of the following dcclarations: Dcnmlitiorr Pcrmits-Asbcstos Notification Fedcral Regulations (Title 40. Part6) -Requircd lrttcr of Notification _l ccrtify that the fcdcralregulations rcgarding asbcstos renmval arc not applicable to this projcct. -l ."r,i),har I havc rcad this application and statc that thc abovc infornration is corrcct. I agree to comply ordinanccs and State [:ws rclating to building construction, and hcrcby authorizc reprcscn'lltives of this City with all City and County and County lo cnlcr upn thc abovc nrcntioncd propcrty fbr Allplicanl or Agenl Pernrilee nanle t purF)scs. o,,", D{f oy'u( Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenVl nsu lation Roof Sheathinq Shear Wall ,/-) Framinq lnsulation/Enerqy I / Drywal!q l0 LI D6PV Ext./lnt. Lath Brown Coat lt/asonry Pool Fence I T-Bar t/Lo.7,(DguDr'/ Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif \\rl /a FINAL \\'(I Certificate of Occupancy Notes, Remarks, Etc. C DWT a