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BU!LDING- INSPECTOR RECORD SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hrcby aflirm undu paalty of pcrjury thar I m exmpt from the ContractoE' Licffic Law for thc followitrg l@n (Se.7031.5 Busin6s atrd Profsion Codc): Any City or County which requirc a pomit to coretruct, alto, improvq ddnolish or rc?air ay structuc, prior to its issumce. also rcquire thc applicot for such pcrmil to file a signcd statmot thal tE or shc is licoscd pmwt to the provisiom of thc Contractor's Licenscd I:w (Chaptr 9. Comcncing with Setion 7000 of Division 3 of the Buins ud ProfcsiomCode)orthathcorshcisqcmptthqcfromedthcbasisforthcallcgcdcxmption. AnyviolationofS6,tion?03l.5byey spplicetforapennitsubjetsthc applicattoacivilpemltyofnotmorcthufivchundrcddollas($500). _1, 6 om6 of thc pro6rty, or my mploye with waga c thcir slc compcnsarion, willdo thc wod< fld thc sructrc is rct intodcd or olIqcd for slc (Sc.7044, Buins ud Profeioro Code: Thc Comncror's Lic@ ljw do6 not apply to u omc of thcptopsry whobuil&orimprorctlu@tratdwhodesuchwd<himclforhmlforthrcughhisorhcommploye. providcd that such impromts rc rct intodod or ofrscd for slc. If, howwa. thc buiHing or imprcvmt is sH within onc )ar ofcomplrrior thc Owns Buildq will have the h!d6 ofproviu thd he or she did not build or imprcvc thc popcty for thc prrpos of slo. _1. as owner of the property. am exclusively contracting with licensed contractors lo construct thc project (Sec. 7U4, Business and Profiession Code: The Contractor's License Law does not apply to an owner of propcay who builds or improves thereon. and who contracts for such projects with a Contracto(s) licensed pursuant to the Contractor's License taw). -l arn exempt under Scction-, B. & P.C. for this reason. \ryORKERS' COMPENSATION DECLARATION I hereby alfirm under penalty of perjury one of the following declarations: _l have and will maintain a Certilicate of Consent to Self-lnsure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the pcrfonnance of the work for which the pennit is issued. _l have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this pcnnit is issued. My workers' compensation insurance carier and policy numkr are: Policy ,?2.9-zz _l ccrrify that in the performance of the work for which this perrnit is issued. I shall not employ any person in any manner so ils to bc.come subject to the workers'compensation laws of California. and agree that if I should bccome subjcct to the workers' compensation provisions of Section 3700 of the labor Code. I shall. forthwilh cornply with thosc provisrons. WARNTNC: Failurc to sccure workers' civil frnes up to one hundred thousand compensation coverage dollars ($100,000), in r is unlarvful. and shall subject an employer to criminal penahies and addition to the cost damages as provided for the Sertion 3076 of the Labor Code, interest and attorney's fecs. I hereby aflirrn under penalty of perjury that I arn licensed 9 (cornmencing rvith Sectiorr 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License c Nurnbcr:Z W I hercby affrm undo pcnslty of pcrjury thal thft is a coEtruction knding agmcy for the po fomcc of thc work for which this pqmit b isucd (Sc. 3097, Civ. C.). Lender's Nanre: Lcndcr's Address: APPLICANT DECLI\RATION I hereby afiirm under penalty of pcrjury one of the following declarations: Demolition Pennits-Asbestos Notification Federal Regulations (Title 40. Part6) _Requircd Lettcr of Notification _l certify that thc lbderal regulations regarding asbestos removal are not applicable to this project. -l cerri$ that I have read this application and state that the akrve infonnation ordinances and State Laws relating to building construction, and the above mentioncd propeny for inspection Applicant or Agent l'crnrilec nilnlc , o^ru,'7-27-Z) Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/Ve nUl n s u Iatio n I rl .D Roof Sheathinq U\t.Yt^bnrry 5vl Shear Wall Framinq Insu lation/Enerqy Drywall Ext./lnt. Lath Brown Coat Masonrv Pool Fence T-Bar Handicap Req. Deputy Final Report Enqineer Fina! Report Flood Zone Certif Ir FINAL eI t2la frfvldn Certificate of Occupancy Notes, Remarks, Etc. Carrier:- """, ?L7;z( is corroct. I