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BUTLDTNc: rNgPEcroR REcoRD SITE-WORK DATE ID/SIG.COMMENTS OWNER BUTLDER DELCARATION I hcrcby aflirnt undcr pcnalty of pcrjury that I am cxcmpt frcm thc Contrsctors' Liccnsc hu for thc following rcasn (Scc.7031.5 Busincss arxl Profcssion Codc): Any City or County which rcquires a Frmit k) construct. altcr, improvc. dcrclish or rcpair my slruclurc. prior to ils issumc, alm rcquircs thc applhstrl for such [Ermil to filc n signcd statcrrcnl thnt he or $c is liccn$d pursuant to lhc pmvisions of thc Controctor's Liccnrcd law (Chrytcr 9, Commcncing with Scc]ion 7000 of Division 3 of thc Business and P(r'cssions Codc) or that hc or shc is cxcmpt thcrcfrom and thc basis for thc alhgcd excmption. Any violation ofScction 7031.5 by any r applicant for a pcrmit subjccts the applicsnt to a civil pcnalty of lot morc than fivc hundrcd dollars ($500). -1. as owncr of thc propcrty, or my ernployccs with wagcs as thcir solc compcnsation. willdo thc work and thc stnrcturc Ls not intcndcd or otlcred for salc (Scc.7M4, Busincss and hofcssions Code: Thc Contractor's License Law does not apply to an owncr of thc propcrty who builds or improvcs thcreon, and who docs such work hinrsclf or hcrsclf or through his or hcr own employces. provided that such improvcmcnts are not intcndcd or offcrcd for salc. lf. howcvcr. thc building or improvcnrcnt is sold within onc ycar of cornplction. thc Owncr Buildcr will havc thc burdcn of proving that he or she did not build or irnprovc thc propcrty for thc purynsc of salc). ? ; -1. as owner of the propcrty, am cxclusivcly contracting with liccnscd contractors to construct thc projcct (Sec. 7U4, Busincss and Profbsskrn Codc: Thc Contractor's Liccnsc Law docs not apply lo an owncr ol'propcrty who builds or inrprovcs thcrcon. and who contracts for such projccts with a Contractor(s) licenscd pursuant to thc Conlractor's Licensc Law). _l amcxcmpt undcr Scction_, B. & P.C. for DFCLARATION I hcrcby alTirrrr undcr pcnalty of pcrjury one of the tbllowing dcclarations: -l have and will rnaintain a Ccrtificatc of Consent to Sclf-lnsurc lbr workcrs'compcnsation. as providcd for byScction 3700 of thc Latxrr Codc. ltrr thc pcrforrnancc of thc work flor which thc pcrmit is issucd. -l havc and will nraintain workcrs' cornpensation insurancc, as rcquircd by Scction 3700 of thc l.abor Codc, for the pcrforrrunce of thc work for which this prmit is issucd. My workcrs' compcnsation insurancc carricr and plicy numbcr arc: Policv Numbcr: Exoires: -l ccrtify that in thc pcrtbrnuncc of thc work for which this pcrrnit is issucd, I shall not enrploy any pcrson in any nunncr so as to bccomc subjcct to thc workcrs' comJrcnsation laws of California. and agrcc that if I should bccornc suhjcct to thc workers' compensation provisions of Section 3700 of thc Labor Codc, I shall. forthwith cornply with thosc provisi<lns. WARNING: Failurc to sccurc workers'contpcnsalion coverage is unlawful. and shall subjcct an cmployer to criminal and civil fincs up to onc hundred thousand dollars ($100.000), Scction 3076 of thc Latxrr CcxJc. intcrcst and attorncy's lbes. in addition to lhc cost of cornpcnsation. danugcs us thc L I)I.]C'I,AIL\'I'ION I hcrcby alllrrn undcr pcnalty of prjury that I arn liccnsed undcr provisiorr of Chaptcr 9 (comnrcncing with Scction 7000) of Division 3 of thc Busincss and Profbssions Codc, and my liccnse is in lull forcc and cf lbct. License Class: Licensc Number: W I hcrcby aftirm undcr Fnalty of Frjury thst therc Ls { @nstruction lcnding agcncy for thc pcrfomrcc of Ihc work for which this Ismit ir issucd (S&. 3097, Civ. C,). hndcr's Nam: Lrndcr's Address: APPLICANT DECLARATION I hcrcby affinn undcr penalty of perjury onc of thc following dcclarations: Dcrnolition Pcrmits-Asbcstos Notification Fedcral Rcgulations (Title 40, Part6) -Rcqu ired lrttcr of Notification with all City and County abovc nrcntionctl propcrty lbr Applicant or Agrnl l)ernritee nanre and County to cntcr ugnn the Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenVl nsu lation Roof Sheathinq Shear Wall Framinq '?-lt-?t Ydt' cllL lnsu lation/Energy Drywall Ext./lnt. Lath Brown Coat [t/asonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif. FINAL O--lt-l 4t td j'l Certificate of Occupancy Notes Remarks , Etc. -P a Date: Contractor: ccrtity that thc fcdcralrcgulations rcgarding asbcstos rcrrrovalare not applicahlc to this projcct. ccrtity that I havc rcad this application and statc lhat and State Laws rclating to building