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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/S!G.COMMENTS OWNER BUILDER DELCARATION I hcrcby affirm undcr lrcmlty of pcrjury thol I m cxcmpt liom thc Contractor' Liccnrc ljs for thc folkrwing rea$n (Ss.7031.5 Busincss and Profession Codc): Any Cily or County which rcquircs a Frmit to construcl. allcr. improvc. dcmlish or rcJEir uy structurc. pdor lo its issuancc, also rcquircs lhc applicanl for such Frmit lo filc a sigred statcmnt thal hc or shc is liccnsed pursuant ro thc provisions of thc Conlractor's Liccnrcd law (Chaptcr 9. Commcncing wih Scclion ?00O of Division 3 of Ihc Busincss and Prcfcssions Codc) or that hc or slrc is cxcmpt thcrcfrom ed thc bnsis for Ihc allcgcd excmflion. Any violalion of Setkrn ?03 I.5 by any rpplicant for a lrcmit subjEts thc applicant to a civil pcnally of nol mrc than five hundrcd dollas (3500). _1. as owncr of thc propcrty, or nry employecs with wagcs as thcir sole compensation. will do thc work and thc structurc is not intendcd or oft'crcd for salc (Scrc.7044. Busincss and Profcssions Code: Thc Contractor's License Law does not apply to an owner of thc propcrty who builds or funprovcs thcrcon. arxl who docs such work himself or herself or through his or hcr own empbyccs. providcd that such improvcnrcnts arc not intcndcd or offcrcd for salc. lf, however. thc building or improvcnrcnt is rcld within onc ye{r of comphtion. thc Owner Buildcr will have the burdcn of proving that hc or shc did not build or improvc thc progrcrty for thc purpse of mh). _1. as owncr of thc propcrty. am cxclusivcly contracting with liccnscd contractors to construct thc projcct (Scc. 7U4, Ilusincss and hofcssionCode: TheContractor'sLiccnsc[,awdocsnotapplyloanowncrofpropertywhobuildsorintprovcsthcrcon. and who contracts for such projects with a Contractrlr(s) liccnscd pursuant to thc Contractor's Liccttsc Law). _l anr undcr Scction_. B. &lirr this ,()t//v OgCLnn {rION I hcrcby affirm undcr pcnalty of pcrjury onc of thc following dcclarations: _l havc and will maintain a Certificatc of Consent lo Scll-lnsurc for workers' comlrcnsation, as provided for by .Scction 37fi) of the L-abor Code. for thc grcrfornunce of thc work for which thc Jrcrmit is issucd. _l have and will maintain workcrs' compcnsalion insurancc. as rcquircd by Scction 3700 of the l.abor Codc. for thc Jrcrformancc of thc work for which this prmit is issucd. My workcrs' compcnsation insurancc carrier ad plicy numbcr arc: Policv Numbcr: Exnires: _l ccrtify that in the pcrfornrancc of thc work lirr which this pcrnrit is issucd. I shall not cnrploy any lrcrson in any rnanncr so as to bccorrrc subjcct to the workcrs'cornpcnsation laws of California, and agrec that if I should bcconrc subjcct lo thc workcrs' compcnsation provisions of Scction 37ff) of the l-abor Code. I shall. forthwith comply with thosc provisions. WARNING: Failure to secure workcrs'compcnsation covcragc is unlawful, and shall subjcct an empkrycr to criminal pcnaltics and civil fincs to one hundrcd thousand dollars ($100.fim). in addition to lhc of compensation, damages as lhc .Scction of thc Labor Codc. intcrcst and allorrrcy's t'ccs. / t)t,lcl,AltA'l'l()N I hcreby affirnr undcr penalty of pcrjury that I anr liccnscrl undcr provision of Chaptcr 9 (cornmcncing with Scction 7000) of Dr yision 3 of thc Busincss and Profcssions Codc, and nry liccnsc is in full force and cffcct. Liccnsc flolo. W I hcrcby affrm undcr Fnalty of Frjury that thcrc is a @nstructk n bnding agercy for lhe pcrformrcc of thc work for which thls prmit is issucd (Se. 3097. Civ. C.). lrndcr's Name: Lcndcr's Acldrcss: APPLICANT DECLARATION I hcrcbyaflirmunder pcnalty of perjury onc o[the following dcclarations: Dcnxrlition Pcrmits-Asbestos Notification Fcdcral Rcgulations (Titlc 40. Part6) -Rcquired Lcttcr of Notification rcrnovalarc nol applicablc to this projcct. atxrvc inlirrnration is corrcct. I agrcrc to comply with all City and County of this City and County lo cntcr upon thc atxlvc mcnlioncd property for inspcction Applicant or Agent Pemtilee name hercby auth<lrizc Oav,r 6 _/r{-LO?l Set Backs Forms/Stee!/Holdowns Erection Pads UFER Ground SLAB Floor Su bf Ioor/VenVI nsu Iation Roof Sheathinq Shear Wall Framinq lnsulatio nlEnerqy 7-l L -2t lg,?,rd 9z- Drywall t -?- ?-r }lri.f, .0u Ext./lnt. Lath Brown Coat [Masonry Poo! Fence T-Bar Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif j< FINAL l) -, {.1 I Fr{?1) Certificate of Occupancy Notes, Remarks, Etc. Carrier: Licensc Numbcr: