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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hreby affinn unde pcnalty of pojury thar I m cxâ‚¬mpt fiom thc Contraclo6' Lic@sc Law for thc following t@n (Sw.7031.5 Businas md Prcfasion Code): Any City or Couty which rcquire a pqmit to @6truct. altc, improvc, dcrnolish or repoir uy' strucluc, prior to its issuocc, also requirG thc applicer for such pcrrnit to filc a signed ststmmt that hc or shc is lic$ed pmumt to thc provisioG of thc Contrrctor'E Licosed taw (Chaptq 9, Comcncing with Setion 7000 of Division 3 of the Busine ud PrcfesionsCode)orthalhcorsheisexmptthsefromedthcbasisforthcallcgcdcxmptiotr. AnyviolationofSdionT03l.5byily applicant for I pqmit subjets the applicut lo a civil pemlty of not more the fivc hundrcd dollrs ($5@), _1. as owner of the property. or my employees with wages as their sole compensation. willdo thc work and the structure is not intcnded or offered for sale (Sec.7044. Business and Professions Code: The Contractor's License law does not apply to an owner of the property who hrilds or improves thereon, and who does such work himself or herself or through his or her own employees. provided that such improvements are not intended or offered for sale. I[, howerrer. thc building or improvement is sold within one )ear of complaion. the Or,vner Builder will have the hrden of proving tha he or she did not build or imp,rove the propoty for the purposc of sale). -1. as owner of the propâ‚¬rty, arn exclusively contracling with licensed contraclonr to construct thc project (Sec. 7044, Buiness and Prcficssion Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projccls with a Contracto(s) licersed pursuant to the Contractor's License l-aw). -l am exempt under Section-, B. & P.C. for this reason. Dnte' O*ner' WORI(ERS' COMPENSATION DECLARATION I hereby affrnn under pcnalty of perjury one of the following declarations: -l havc and will rnaintain a Certificate of Consent to Self-tnsure for workers' compensation, as provided for by Scction 3700 of the Labor Code. for the perfonnance of the work for which the permit is issued. 1#have and will rnaintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the pcrformance of work for which this permit is issued. My workers' compensalion insurance carrier and policy numbcr are: rt/v Cytt *&,)I Policy L oi__ oe *y _l certify that rn the performance of the work for which this perrnit is issued, I shall not so ,rs to becorne subject to the workers'compensation laws of Califomia, and agree that if I employ any pcrson in any manner should become subjcct to the workers' compensation provisions of Section 3700 of the Labor Code, I shall, forthwith comply with thosc provisions. WARNING: Failure to secure workers' compensation coverage is unlawful, and shall subject an onployer to r;riminal pcnalties and in addition to the cost of compensation. darnages as provided for the or,", Q-0Q-L) DECI"ARATTON I hereby aflinn under penalty of perjury that I am licensed under provision of Chapter 9 (cornmencing with Section 7000) of Division 3 of the Business and Professions Code. and my license is in full force and effect. License Number:t0o7Os-4 Dil", 0q- Ocl - L\ Contracro, Bffecrr gttU f oruSfzuCr/arJ CONSTRUCTION LENDING AGENCY I h@by affm und6 penalty of pcrjury that thqc is a consruction lcnding agocy for thc pqfomucc of thc work for which this p6mil i3 issued (56. 3097. Civ. C.). lrnder's Narne: Lender's Address: APPLICANT DECLARATION I hercby affinn under pcnalty of pc'rjury one of the following declaratioo* Dernolition Perrnits-Asbestos Notilication Federal Regulations (Title 40, Part6) _Required Letter of Notification -l cerri$, that the federal regulations regarding asbestos removal are not applicable to this project. a(r*ify that I have read this application and state that with all City and County and County to enter upon theordinances and State Laws relating to above mentioned property for Applican( or Agent Itcrntitcc nlunc a-z) Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/VenUI ns u lation Roof Sheathing Shear Wall Framing Insulation/Enerqy Drynruall Ext./lnt. Lath Brown Coat Masonrv Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif tl D*n* P*-,1 / Et / brn-,uh/u Jtilax/I ,\IV FINAL rclhlh I )4s Certificate of Notes, Remarks, Etc.l Carrier:-