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BUILDING- INSPECTOR RECORD SITE-WORK DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION I hcreby allirm undcr Fnaly of lrcrjury lhat I m excrpl fmm thc Contraclor' Liccn$ [lw for thc followirg rwn (Sc.7031.5 Busincss ard Pmlbssion Codc): Any City or County which rctuircs 8 frcmit to @nstrcl, altci imprcrc, dcmlish or rclEir ily slruduc prior lo its issumc, also rcquircs thc applicant for such lErmit to filc a signcd st.lcrcnt that he or slf, is liccnrcd pursuot -to the Fovisions of lhc Controctor's Liccnpd [rw (Ch8ptcr 9, Commrcing wilh Sclion 7000 of Divlsion 3 of the Busiress ud - Prcfessk ns Code) or Ihlt he or shc ir cretrpt ttmfrcm airC lhe basis for thc allcgcd cxerpiion. Ary violatbn of SNtbn TOJ l .5 by ey : spplicsnt for a pcrmit subjets lhe applicant to 8 civil pcnalty of not mrc Ihe five hundred dolhs ($500). --1. a.s (rwircr of thc propcrty. or my cnlployecs with wagcs as lheir solc compcnsation. willdo thc work arxl thc stnrcturc is rxlt intcndcd <lr offered f<lr sale (Sc.c'.7044 Busincss and hofcssions Codc: Thc Contractor's Liccnsc law docs not apply to an owncr of thc propcrty who builds or inrprovcs thcrcon. and who does such work hinsclf or hcrsclf or through his or hcr own employecs. provided that such improvcnrnts arc rxlt intcndcd or offered for sale. If, howerrr, thc building or irrryrrovcnrnt is sokl within onc )car of comphtion. thc Owrrcr Buildcr will have thc burdcn of proving that frc or she did not b,uih or improvc ttrc property for thc pur;nsc of sale). __1, as owncr of thc proprty. amexclusivcly contracting with licenscd contractors to conslruct thc projoct (Sec. 7W, Busincss and Profcssion Codc: The Contractor's Liccnsc Law docs n<lt apply lo an owner of propcrty who builds or improves thcrcon. and who conlracts fbr such projects with a Crnlractor(s) liccnscd pursuant to thc Contraclor's Liccnsc law). tbr this ( )rvner: DECI ARATION I hcreby alTirm undcr pnalty of prjury onc of thc following clcclarations: -_l have and will maintain a Ccrtificatc of Conscnt to Sell'-lnsurc for workcrs'compcnsalion. as povidcd for bySection 3700 of the L-abor Codc. for the pcrformancc of thc work for which the pcrmit is issued. _l havc and will maintain workers' compcnsation insurance. as rcnuircd by Scction 3700 ol'the [:bor Code. for the performance of thc work for which this permit is issucd. My workcrs' comlrcnsalion insurance carricr ad plicy numbcr are: Policy _l certify that in thc pcrformance of thc work lbr which this pcrmit is issucd, I shall not employ any pcrson in any rnnner sn as to bccomc subpct to lhc workers' compensation laws of California. and agrec that if I should bcconrc subjecl to ttrc with thosc provisions. an cnrploycr to crinrinal ics antl civil fincs up to onc hundrcd thousand dollars ($100.000).to thc cost danuges as thc atlonrcy's I hcrcby ulfirnr unclcr pcnalty of pcrjury thll I arn liccnscd provision of Chaptcr 9 (comnrcncing with Seclion 7Un) of Division 3 of the Business and hofcssions Codc. and my liccnse is in full forcc and et'fcrt. Licensc Cluss: l-iccnse Nutnbcr: Date:__Contractor:_ CONSTRUC'TION LB{DING AGENCY I hcrcby rftirm urdcr Fnalty of JErjury that thm is a construction bnding agcrcy for thc lrcrforlllmc of lhâ‚¬ work for which this Ism[ b isrucd (Scc. 3097, Civ. C.). [-cnder's Narnc: I.cncicr's Aclclrcss: APPLICANT DECLARATION I trcrcby alfirmundcr pcnalty of pcrlury onc of the following declarations: Dcmolition Permits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40, Part6) -Requ ircd l,cttcr of Notification _l certify that thc federal rcgulations rcgarding asbcstos rennval are nol applicablc to this proj<xt. _l ccrrily lhat I huve rcad this application and statc that thc ahrvc information is corrcct. I agrec with all City and County ordinances and Statc Lrws relating to building above nrntioncd pro;rcrty for Applicanl or Agenl Pernriter. nar.le authorize rcpresentat ivcs tnd Set Backs Forms/Stee!/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loo r/VenU! ns u I atio n Roof Sheathino Shear Wall Framinq '? - l9 -Ll d>Otln- lnsulation/Energy Drywall Ext./lnt. Lath l-l L -21 I Y*â‚¬'tz Brown Coat 6-tqL4r EIrJa1eâ‚¬,llr JMasonrv Pool Fence T-Bar Handicap Req. Deputy Final Report Enqineer Final Report Flood Zone Certif ,fo,euel 83.*t SV9*d .U FINAL pfiq /u Fu) 5'l Certificate of Occupancv Notes, Remarks, Etc. Rev. 08-07-201 5 _l am cxcrnpt Dnte:__ Carrier: