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BUILDING. INSPECTOR RECORD SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DET,CARATION t hacby affm unda pculty of pcjury that I m crcmpt tom thc Contre{oB' Lic@ [aw for thc following @n (5â‚¬.7031.5 BNins atrd Profsion Code): Any City or County which rcquirc a pomit to @struct, altq, imprcvg <krrclish or rrpair my structuc. prior to its isumcc, also rcquirc thc applicut for such pqmit to filG a signcd stalmot th8t hc or drc b licGed plmad to thc provisioE of thc Contraaor's Licmscd law (Chapt6 9, Comocing wirh Setior 7000 of Division 3 of thc Buins od Prcfeions Codc) or thst hc or shc b qcmpt thqcfrom sd thc b6sis for thc allcged croplion, Any violation of Sdion 7031.5 by uy applicut for a pfinit subjets thc applicut to a civil pcnalty of not morc thm five hundrcd dollm ($500). _1. as owner of the propcrty, or my employes with wagcs as their sole compersation. will do the work and thc structure is not intcndcd or offered for sale (Sec.7044, Business and Professions Code: The Contractor's Licerse Law docs not apply to an owner of the propory who builds or improvcs thcreorL and who docs such work himself or herself or through his or hcr own employees, providcd that such improvonents are not intcndod or offcrcd for sah. I[, howevcr. the building or imp,roverncnt is rcld within one ]rcar of complaion, the Orvncr Builder will have the hrden of proving thd he or she did not build or improvc the propory for thc purposc of sale). _1, as owner of the propcrty, arn cxclusivcly contracting with liccnscd contraclors to construct thc project (Sec. 7044, Btsincss and hofession 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 Contraclo(s) liccrsed pursuant to thc Contractor's Liccnse l-aw). -l am cxempt under Section-, B. & P.C. for this reason. Owner: WORKERS' COMPENSAT DECLAITATION I hereby affrm under pcnalty of perjury one of the following declarations: _l have and will maintain a Certificate of Consent to Self-lnsure for workers' compensationt as provided for by Section 3700 of the Labor Code, for the performance of the work for which the perrnit is issued. _l have and will maintain workers'insurancc. as by Section 3700 of the Labor Codc, for thc pcrformance of the work for which ffi issued.workâ‚¬rs'and policy number are: n \--U 1 d \0 l)/rLPolicy _l ccrti& that in the performance of the work for which this pcrrnit is issucd, I shall not employ any person in any manner so as to become subject to the workcrs'compensation laws of California, and agree that if I should bccome subject to the workers' compensation provisions of Section 3700 of the Labor Code. I shall. forthwith comply with thosc provisions. WARNING: Failure to sccure workers'compensalion coverage is unlawful, and shall subject an onploya to criminal penalties and civil fines to one hundred thousand dollars ($100.000), in addition to the cost of compensation, damages as provided for the Section Code, interest Itr,l (^ I hercby affrm under penalty of perjury that I am licensod 9 (cornmencing with Scction 7000) of Division 3 of the Business and Profcssions Codc, md my licensc is in full forcc and effcct. a License A crl ogq. W I h@by affm unda pcnalty of pcrjury thd thw is a coDdruclbn boding rg6cy for thc pqfmcc of thc wo* for which this pqDit b issucd (Se. 3097, Civ. C.). Lcndcr's Namc: Lcnder's Address: APPLICANT DECLARATION I hoeb,y affinn undcr penalty of perjury one of the following declarations: Demolition Permits-Asbcstos Notification Federal Regulations (Title 40, Part6) -Required l-rtter o f Notification _l certiff that the federal regulations regarding asbcstos rqnoval arc not applicable to this project. _l ccrri$ that I have rcad this application and state that thc above information is correcl. I agrec to comply ordinances and State Laws relating to building construction and hereby authorize represcntatives of this City with all City and County and County to u1xrn the above mcntioned properry for Applicant or Agent ? rn q lz Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloor/Venul nsu latio n Roof Sheathing Shear Wall Framinq lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req. Deputy Final Report Enqineer Final Report Flood Zone Certif , FINAL t0 o u DA,*n / Certificate of Occupancy Notes, Remarks, Etc. -Expires: