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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG COMMENTS OWNERBUILDERDELCARATION \ I hcrcby allirm undcr lrcnally ol Frjury that I am cxcmpt from thc Conlract)s' Liccnsc lraw for thc lirlkrwing rcapn (icc.70Jfi Busilcss ud Profcssion CqIc): Atry City or County which rcquircs a lErmt l{r ?ofisttucI. allcl improvc. rlcmlish or rc[dr ily sIructurc, ltrirr kr its issuarec, also rcquircs thc applicant for such lErmit kr filc a signcd statcmnt that hc or she is liccnsd pursuant to thc lr]v$ions of thc Contractor's Liccnrcd tav (Chaptcr 9, Comrcncing uith Ssrion 7000 of Divisi(rn .J of thc Busincss and Prutbssi(rns Code) or that hc or shc is cxcmpt thcrcliom and thc b.sis for thc allcgcd cxcmption. Any violalion of Sclion 703 1.5 by any applicant lor a Frmit subjccts thc applicant kr a civil pcnalty of not morc than tivc hufrkcd dollaff ($500). _1, as owncr ol'thc propcrty, or my empk)yccs with wagcs as lhclr solc compcnsalion, will do thc work arxl thc structurc is not intcrxled or oll'crcd firr salc (Sec.7044, Busincss and Profcssions Cule: The Conlractor's Liccnsc [-aw drtcs not apply lo an owner of thc pn)pcrty who builds or impn)vcs thcrc()n. and wtxr drrcs such wort himsclf or hcrsclf or through his or hcr own cmployces. providcd that such improvcrncnts are not intcndcrl or ofl'crcrl tirr salc. lf, lxrwcvcr, thc buikling or improvcnrcnt is sokJ within onc ycar of comphtion. the Owncr Buikler will havc thc burdcn ol'proving that hc or shc did rxrt buikl or improvc thc pnrpcrty for the purgxrsc of sak). _1, as ()wncr of thc profrcrty. am cxclusivcly contracting with liccnsed contractors to construct the projcct (Scc. 7(W, Busitrcss and Pnrlbssion Codc: The Contractor's Liccnsc Law does not apply to an owncr of property who builds or improves thercon, and who contracts lirr such projccts with a Contractor(s) liccnscd pursuatrt to thc Grntractor's Licensc Law). _l am cxempt untlcr Scction_, B. & P.C. tbr this rcason. Date: WORKERS' COI\T PENSATION DECLARATION I hercby all'irm unrlcr pcnalty of perjury onc of thc lirlhrwing dcclarations: _l havc and will maintain a Ccrtilicate uf Conscnt to Sclf-lnsure tbr workcrs' comJrcnsation, as providcd tirr by Scction 3700 of thc Labor Codc, lirr thc pcrlirrmancc of thc wurk lirr which the Jrcrmit is issucd. _l havc and will maintain workers' comJrcnsation insurancc, as rcquircd by Scction .17fi) of thc Labor Codc, lilr the Jrcrtirrmancc of thc work lirr which this ;rcrmit is issucrl. My workers' compensation insurancc carricr and grlicy numbcr arc: Policv Numhcr: Exnires: _l certily that in thc pcrlilrmance of thc wrlrk lirr which this Jrcrmit is issuctl, I shall not employ any [rcrson in any manncr so as to bccomc subjcct to thc workers' comJrcnsation laws of Calitirrnia, and agrcc that if I should bccomc suh.icct to thc workcrs' compcnsation provisions of Scctkln 3700 of thc Latxlr Culc, I shall, lirrthwith comply with thosc pnrvisions. WARNING: Failurc to sccurc workcrs'compcnsation covcrage is unlawt'ul, and shall subjcct an cmploycr to criminal Jrcnaltics and civil lincs up to onc hundrcd thousand dollars (S100,Urc), in adtlition lo thc cost of comJrcnsation, damagcs as providcd for thc Scction -1076 of thc Latxlr Culc, furtcrcsl and attorncy's D,rc,;u+ r88{ DECLARATION I hercby allrm undcr Jrcnalty of pcrjury that I am liccnrctl under provision of Chaptcr 9 (commcncing with Sectkrn 7U)()) of Division 3 of thc Busincss and Prol'cssions Codc, and my liccnsc is in full torcc and cll'cct. Liccnsc lo,l0 AIl W I hcEby atlirm undcr lEnalty of Frjury that thm is a constructbn bnding a8cfty for thc Frfomet of thc work for which this Jsmit is issucal (Scc. 3(x)7, Civ. C.). [-cndcr's Namc: l.cndcr's Addrcss: APPLICANT DECLARATION I trcrcby allirm undcr Jrcnalty of Jrcrjury one of thc lirlkrwing dcclarations: Dcmolition Pcrmits-Asbcstos Notitication Fcrlcral Rcgulations (Titlc 40, Part6) _Rcquircd lrttcr of Notification _l ccrtily that thc l'cdcral rcgulations rcgarding asbcstos rcmoval arc rx)t applicahlc to this projcct. _l ccrtily that I havc rcad this application and statc that the atxrvc inlirrmation is corrcct. I agrcc to conrply represcntativcs of this City with all City and County and County lo cnter up)n thcordinanccs and Slatc Laws relating to building atxlvc mcnlroncd proprty ti)r Applicant or Agent IPennitee nanre ion. and hcrcby authorizc - 902.,1 Set Backs y',zz r'71 /',cz,7 ^aDForms/Steel/Holdowns TIMlfr I ?hilil1 igo Erection Pads I I I I .a- UFER Ground a SLAB Floor TlMlat ,frhth Su bf loor/VenUI ns u Iation Roof Sheathinq \f r-?, I nr*7"h Shear Wall ,),/ lJ n '-/ Framing lnsulation/Enerqy \-- 2{&l h.?4 il\ Drywall I )- 47-Y*) EftVlnt. Lath {.3o4 ?c ?r Efrown Coat -/ Masonry Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif. FINAL I '.Ct>Je_145 ryl Certificate of Occupancy Notes, Remarks, Etc. Flr:rr nP=n7 3fi1 q, ak\