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INSPECTOR RECORD SITE-WORK DATE ID/S!G GOMMENTS OWNFR BUILDER DEI CARATION I hereby affirm under penalty of perjury that I am exempt form the Contractors' Liccnse Law for the following reason (Sec.7031..5 Business and Profession Code): Any City or County which requires a pennit to construct. alter. improve, demolish or repair any structure, p,rior to its issuance. also re{uires the applicant for such pennit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor's l-icensed Law (Chapter 9. Commencing with Section 7000 of Division .1 of the Business and Professions Code) or lhat he or sheisexernpttherefromandthebasisfortheallegedexemption. AnyviolationofSectionT0Sl.5byanyapplicantforapernritsubjecsthe applicant to a civil penalty of not more than fir'e hundred dollars 1$-500). 91. ,r owner of the property. or my employc.es w'irh rvages as their sole compensation. will do the work and rhc structurâ‚¬ is nor intendcd or offered for sale (Sec.7044. Business and Professions Code: The Contractor's License Law does not apply to an ownâ‚¬r of the p,ropcrty who builds or improves thereon. and who does such work himself or herself or through his or her own employees. provided that such irnprovernents are not intended or offerod for sale. lf. howwer. the building or improvement is sold within one year of completion, the Owner Builder will have the burden of proving that he or she did not build or imp,rove the propertv for the purposc of sale). I11. .r owner of the property. am exctusively contracting wirh licensed contractors to constnrct the project (Sec. 7M4. Business and Profession Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon. and rvho contracts for such pro.iects with a Contracto(s) licensed pursuant to the Contractor's License Law). !9 I arn exempt under Section - . B. & P.C. fcrr this reason. WORKF'RS' COMPF'NS ATION ]IF'CI { ITATION I hereby alTinn under penalty of perjury one of the following declarations: !t f,"*,. and will mainrain a Ce'rrificare of Consenr to Self-lnsure for rvorkers' compens:ltion. as provided for by Section -1700 of the l-abor Code. for the performance of the work for which the permil is issued. YES -_l have and rvill maintain worken'compcnsation insurance. as required by Section 3700 of the LaborCode, for the performance of the rvork for which this permit is issued. My workers' compâ‚¬nsation insurance carrier and policy number are: Carrier:_ Policy Number ltlO ADWC239685 o21oit2022 [.,xpires: __ I certify that in the performance of the u'ork for rvhich this permit is issued. I shall not employ any person in any manner so as to become subiect to the rvorkers' compensation larvs of Califomia. and agree that if I should become sub.iect to the .vorkcrs' cotnpensation provisions of Section 3700 of the l.abor Code, I shall. forthwith comply with those provisions.. t WARNING: Failure to secure rvorkers'compensation coverage is unlawful. and shall subject an employer to crirninal penalties and civil fines up toone hundred thousand dollars ($100.000). in addition to the cost of compensation. damages as provided forthe Section 3076 of the Labor ('cxle. interc'st and attomey's fees. LI('FNSFN CONTRACTOR NFCI A]TATION I hereby affirm under penalty of per.jury that I am licensed under provision of Chapter9 (commencing rvith Section 7000) of Division .1 of the Business and Professions Code, and my license is in full force and effect. c3e License Class: 56014a License Number CONSTRI.ICTION I ENNING AGENCY I hereby allirm under penalty of perjury that there is a construction lending agercy for the perfornunce of the work for which this pcrmit is issued (Sec. 3097. Civ. C.). "D l-ender's Nanre: I-ender's Address: APPI ICANT NF'CI A]TATION I hereby atlnn under penalty of per1ury one of the followrng declaratrons Denrolrtron Pennrts-Asbestos Notrficatron Federal Regulalrons (Trtle 40, Part6) !1 Required Letterof Notification YEs I certify that the f'ederal regutations regarding asbestos rernovat are not applicable to this project. YES __ I certiS that I have read this application and state that the above information is con'ect. I agree to comply with all City and County ordinances and State Laws relating to building construction. and hereby authorize representatives of this City and County to enter upon the above mentioned property for inspection purposes. Reroof Roof (Diaphragm Sheathing/Frame).a Structural Final ro/rfilflr g{h*64Wn Plumbing Under Floor I Under Slab Rough Shower Pan / Tub Test Water Service Sewer / Sewer Cap Gas Air Pressure Test Plumbing Final Electrical Service (Meter I Panel) Groundang / Bonding Rough Electrical Final Mechanical Gas Air Pressure Test Rough Piping (HW, CW, etc.) Exhaust Ducts Mechanical Final Notes, Remarks, Etc. ,I