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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG COMMENTS OWNI:R BUILDER DELCARATION I hereby aflirm unda poalty of psjury thar I m cxcmpt from thc Contracton' Liccre Law for thc following rmn (Se.7031.5 Busines and Profsion Code): Any City or Comty which rcquira a po'rnit to @n$ruct, alts. improvc. danolish or rcpair oy structue, prior to its issumcc. also rcquire thc applicilt for such pcmit to filc a signcd statmmt that hc or slE h liccns(d pwarn to the provisiore of thc Contnclor's Licoscd l3w (Chapts 9, Commcncing whh Setion 7000 of Division 3 of thc Buine ud PrcfeionsCode)orthathcorshciscxcmptth@fromedthcbasisforthcallcgcdcroption. AryviolationofsdionT03l.5byey applicqnl du* for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). owner of the property. or my employccs with wages as their sole compensation, will do thc work and the structure is not or offered for sale (Sec.7M4. Busincss and Professions Code: The Contractor's Liccrse [aw does not apply to an owner of ,. the properly who builds or improves therqrn. and who does such work himself or herself or through his or her own employces, provided that such improvonents are not intcnded or offered for sale. lf. howwer, the building or improvetnent is sold within one year of complction, the Orvner Builder will have the hrden of proving that he or she did not build or irnprove thc property for thc purpose of sale). _1, as owner of the property, am exclusively contracting with licensed contractors to construct the projcct (Sec. 7044, Business and hofession 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 with a Contracto(s) licensed pursuant to the Contractor's Licerse taw). _l am Section-.for this reason.\ DECLAITATION I hereby affirm under penalty of perjury one ofthe following declarations: -l have and will maintain a Certificate of Consent to Sclf-lnsure for workers' cornpensation, as providcd for by Section 3700 of the Labor Code, for the performance of the work for which thc pennit is issued. -l have and will rnaintain workers' compensation insurance. as required by Section 3700 of the Labor Code. for the pei'formance of the work for which this permit is issued. My workers' compensation insurance carrier and policy numbcr are: that in the pcrformance of the work for which this permit is issued. I shall not onploy any person in any manner if I should become subject to theto become subject to the worktrs'cornpensation laws of California, and agree that 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 onployer to criminal panlties and civil fines up to one hundred thousand dollars ($100.000). in addition to the cost of compensation, damages as provided for the Section 3076 of the labor Code, interest and attorney's fecs.76 I hereby affirm under penalty of pcrjury that I am licensed under provision of Chapto 9 (commencing with Scction 7000) of Division 3 of thc Business and Professions Code, and my license is in full force and effect. Number: W I hwby aflm unda Frulty of psjuy thst th@ is a @rsructbn lcnding agocy for thc pqfomcc of thc rcrk for which this pqrnit b isucd (Se. 3097, Civ. C.). [fldq's Nuc: Lender's Address: APIIJCANLDECT.AEAIIAN I hqlby affm undq penalty of pâ‚¬rjury one ofthâ‚¬ following delaalioru: Dsnolition PmiteAsb6tos Notification Fcddat RcgulatioN (Titlc 40. Pan6) -Rcquircd t tt6 of Notilicalioo -l cqtifu that thc fcdoal regulalioE rslardiry sbGtos rmovd uc not applicablc to this pmjet. -Hlotify tU t t o" Bd this applietion Ed state that thc abovc informatiotr is coret. I agrts to @mply with all city md Coutrty ordi@c6 md Statc ttws rckuing to buildiag consrrudioq sd hqeby authorizc rcprsil8tivB of this City md Couty to at6 upon thc above mentioned property for inspection purposes. Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/VenUI n s u latio n Roof Sheathing Shear Wall Framing lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif / ,tI FINAL Yolrl h, Certificate of Occupancy I I / \,, Notes, Remarks, Etc.I Y v Can'ier: License Class:- Contrector:_ AAA4n