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BUILDING- INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hrcby atfum under panalty of pc{ury that I m cxmpt ftom the Cortracloa' Licre t:w for thc following rusn (Sc.70tt.5 BNin6s dd Profeion Codc): Any City or County which rcquirc a pornit to coNtruct, altc. imprcve dcrrclish or repeir my strucluq prior to its isuucc, also rcquirc thc ryplicat for such pcnnit to filc I signcd statmat thar hc or dE b licascd pmwt to thc prcvisioN of thc Contretor's Liccnscd trw (Chapts 9, Commcing with Setiotr 7000 of Division 3 of thc Buine ud Prcfeiom Co&) or thal hc or shc is qmpt thscfrom ud thc basis for thc allegcd uoplion. Any violation of Scrbn 7031.5 by uy applicmtforaponitsubjctsthc appticettoacivilpâ‚¬mltyofnotmorethafivchundrcddollrs(S500). _1. rN owner of the property, or my employecs with wages as their sole compensalion. will do the work and the stnrcture is not intended or offered for salc (Sec.7044. Business and hofessions Code: The Contractor's Licersc l-aw does not apply to an owner of the property who builds or improves thereon. and who docs such work hirnself or hcrsclf or through his or her own employccs, provided that such improvoncnts arc not interrdcd or offcred for salc. If. however. thc building or improvemcnt is sold within one year of completion, the Oryner Builder will have the burden of proving thd he or she did not build or improve the propoty for the purpose of sale). -1, as owner of the propcrty, arn exclusively contracting with licenscd contractors to construct the pr,oject (Sc. 7044, Brsiness and kofcssbn Code: The Contractor's License Law does not apply to an ownâ‚¬r of property who builds or improvcs thcrcon, and who contracts for such projects with a Contractor(s) licensed pursuant to the Contrac{or's Liccnsc l-aw). -l am exempt under Section-, B. & P.C. for this rcason. Drte: Owner: WORKERS' COMPETISATION DECI.ARATION I hcreby affrrm undcr penalty of pojury one of the following declarations: _l have and will maintain a Ccrtificate of Consent to Self-lnsure for workâ‚¬rs' compcnsatioq as provided for by Section 3700 of the I-abor Codc for thc performance of the work for which the pcrrnit b issued. -l have and will maintain workcrs' compensation insurance, as rcquired by Section 3700 of the labor Code, for the pcrformance of the work for which this permit is issucd" My workcrs' compâ‚¬nsation insurancc carrier ard policy numbcr are: e L tr,\axu4 Policy s L 053 4t -Gl-(.-, _l certiff that in the perforrnance of the work for which this permit is issued, I shall not so as to become subject to thc workers' compensation laws of California. and agree that if I any person in any manner subject to the workers' compensation provisions of Seoion 3700 of the l-abor Code, I shall. forthwith thosc provisions. onployer to criminal paulties andWARNING: Failure to secure workers' compe â‚¬tion coverage is unlawful. and shall r civil fines up to one hundred thousand dollars ($100,000), in addition to thc cost of damages as provided for the Section 3076 Labor Code, interestl-and attorney's fees.I ,D2 DE,('I,ARA'I'ION I hereby affrm under peilalty of pcrjury that I am licensed under provision of Chapter 9 (commencing with Secrion 7000) of Qir;s;5n 3 of thc Business and Professions Code, and my liccnse is in full force and effect. e b c 6 ) e.8 License t, I hmby dfm undo pqnlty of pqjury that th@ is I @rstruclior bndiry agocy for thc pafomecc of thc rcrk for which this pomt b issucd (Se. 3097. Civ. C.). Lender's Name: I-ender's Address: APPLICANT DECLARATTON I hereb,y affinn under pcnalty of perjury one of the following declarations: Demolition Pcrmits-Asbcstos Notification Federal Regulations (Title 40, Part6) -Required Letter of Notification _l certi& that the fbderal regulations regarding asbestos removalare not applicable to this project. is correct. I agree to cornply with all City and County representatives of this City and County to enter upon the above mentioned property for inspection Applicant or Agent Pernritee name - Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloo r/Ve nUl ns u latio n Roof Sheathins 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 lt ,^trC1 bL 5Hâ‚¬Lc WAo 7/p/?-,Lo O\) .< FINAL l6hoht fl,t-rBlt) Certificate of Occupancy t \- Notes, Remarks, Etc. Contrnctor,'L I have read this application and statc that the abovc J t