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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DEIfARATION I h6cby sffm uodq pcsslty of pqjury thst I m qmpt from thc contsac{oB' Licce Lrw for the followirg *S (So.;O:t.S Buines ard Prcfcsion Codc): Ary City or County which rcquirc a pcrnit to @Etruct, dtq, improvc d&uolistr or rcpair my structuc. prior to its isuocc also rcquirc thc applicmt for such pennit to filc I signod statmot that hâ‚¬ or slE b licmcd pwaat to thc Fovisiorc of thc Cotrtetor's Licmscd taw (Chapt6 9. Comacing wirh Serio! 70OO of Division 3 of thc Bwtrei ud Prcftssioro Co&) or thrt hc or shc is cxcmpt thqcfiom ed thc basis for thc allcXcd aoprion. Atry violEtion of Sâ‚¬lbn 7031.5 by ay applimt for a pcrmit subjâ‚¬ls thc applicut to a civil pcrulty of rct morc tha fivc hundrcd dollm ($500). _1, I om6 of thc propcrty. or my mplole with wage c thcir rclc ompcnutioq will do thc wod( and thc ltndrc b mt inrqdcd or olIqcd for ulc (Se.7044, Bwins md Profcsioro Code Thc Contraclor's Lic@ Lrw do6 not agply to m oma of thcpropsry whotuil&orinprostls@n,{dwhodBwhrc*himelforhwlforthrcughhirorheommplolcc. prcvidcd that such improvqmts e rct intodcd or offircd for slc. lf, how, thc tuiHiig or imFovmt is $ld wilhin oDc ]qr of mmpl*io4 thc Ouo Buil{s will harc thc hda of proving tha hc or shc dll mt tuiE or imForc &c prcpoty br thc pupos of eb). _1, as owner of the propertyr am exclusivcly contracting with licensed contractors to construct thc project (Sec. 7044, Business and ltofession Code: The Contractor's License Law does not apply to an owner of propcrty who builds or improves thereon, and who contracts for such projects wilh a Contractor(s) licensed pursuant to the Contractor's Licensc Law). _l am exempt under B. & P.C. for this reason. WORKETLS' COMPENSATION DECLARATION I hereby affrrm undcr penalty of perjury one of the following declarations: _l have and will maintain a Ccrtificatc of Conscnt to Self-lnsure for workers' compeflsation. as provided for by Section 3700 of the Labor Code, for the pcrformance of thc work for which the perrnit b issued.'x the have and will maintain workers' compensation insurance, as by Section 3700 of thc l-abor Code, for the performance of rcarier and policy numkr are:for p,ermit is issuod. My workcrs' Policy aA2? -l certi& that in the performance of thc work for which this permit is issued, I shall not employ any person in any manner so urs to become subject to the workers' compensation laws of California. and agree that if I should become subject to the . workers' compensation provisions of Section 3700 of the Labor Code, I shall, forthwith comply with those provisions. WARNING: Failure to secure workers' compensation coverage is unlawful. and shall subject an qnployer to criminal penalties and civil fines up to one hundred thousand dollars ($100,000), in addition to the cost of cornpcnsation, damag,es as provided for the Section 3076 of the L^abor Codc, intercst and attorney's fees.c,rr", O-2O'Zl I hereby affrm under penalty of perjury that I am licensed under 9 (commencing with Section 7000) of Division 3 of thc Business and Professions Code, and my liccnsc is in full forcc and effect. License W I heby alfm mda pcnalty of pqjury th8t th@ is I @Btruction knding agmy for thc pafommcc of thc work 6r which thb pqmit b issucd (Sc. 3097, Civ. C.). lrnd6's Nmc: - Lcrrder's Address: APPLICANT DECLARATION I hereby affirm undcr pcnalty of perjury one of the following declarations: Demolition Permils-Asbestos Notification Fedcral Regulations (Title 40, Part6) -Required Later of Notification that thc fbderal regulations removal are not applicable to this project. the above with all City and County and County to exter upon the above meirtioned property for Applicant or Agent Perrnitee nRme to and ts b-z I Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloor/VenUl ns u Iation Roof Sheathinq Shear Wall Framing Insulation/Energy Drlnruall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif I{.ol De^, /E^,,a La^nh/a */l oc,.t/t,/ ,U, FINAL /o/{zr tfufiv7. Certificate of Notes, Remarks, Etc. Section orr", Zr- 20- Z\ this application to ,