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BUILDING. INSPECTOR RECORD SITE-WORK DATE ID/SIG.GOMMENTS OWNER BUILDER DDLCARATION I hqcb affim undo pmalty of pojury thst I m cr@pt ftom the Contracton' Licffi L{w for thc following twn (Se.7031.5' Bsin6s ud Profsion Code): Any City or County which requirc a pcrnit to construcl. alle. improvq donolish or rtpair my structue. pflor to ils issuucq also rcquirs thc applicmt for such pcrmil lo filc a signcd statmot thal he or shc b licsEcd pmuilt to th. prcvisioB of the Contractor's Liccnscd taw (Chapto 9, Comcncing with Setion 7000 of Division 3 of thc Buine ad PrcfesionsCode)orthathcorsheisqemflthftfromedtheb6isfortheallescdexmFion. AnyviolationofSEtionT03l.5bymy applicdtforapcnnitsubjetsthc applicottoacivilpâ‚¬nahyofnotmorcthufivchundrcddollm($500). -1. as o\\,ner of the proprerty, or my employccs with wages as their sole compensation. willdo the work and the structtue is not intended or oflered for sale (Sec.70a4. Business and Professions Code: The Contractor's License Law does not apply to an owner of the property rvho builds or improves thereon. and who does such work himself or hcrself or through his or her own employees. providd that such improvanents are not intended or offered for sale. I[, howwer, the building or improvemert is sold within one yâ‚¬ar of cornpletion. the Owner Builder will have the burden of proving that he or she did not build or improve the property for the purposeof sale). -1. as owner of the property. am exclusively contracting with licensed contractors to construct the project (Sec. 7U4, Business and Profession Code: The Contractor's License Law does not apply to an owner of property who builds or improvcs thereon, and who contracts for such proJects rvith a Contractor(s) licensed pursuant to the Contractor's License taw). --l arn exempt under B. & P.C. Oate, r.5 - | C -?-O ?, I 6 Cr{nv! l) I,.(' 1.,\ ll,\'l' l( )N I hereby affirm under penalty of pojury one of the following declarations: -l have and will rnaintain a Certificate of Consent to Self-lnsure for workers' compensation. as provided for by Section 3700 of thc Labor Code. for the perfonnance of the work for which the perrnit is issued. -l have and will maintain workers' compensation insurance. as required by Section 3700 of the Labor Code, for the performancc of the work for which this permit is issued. My workers' compcnsation insurance carrier and policy number are: Policy Number: Expires:, -l certify that in the performance of the work for which this perrnit is issued, I shall not ernploy any person in any manner so as to become subject to the workers' compensation laws of California and agree that if I should become subjc.ct to the workers' compensation provisions of Section 3700 of the Labor Code, I shall. forthwith cornply with those provisions. WARNTNG: Failure to sccure workers' compensation coverage is unlawful. and shall subject an onployer to criminal p'.nlties and civil firnes up to one hundred thousand dollars in addition the cost damages as provided for thc Scction 3076 of the Labor Code. interest and fees. -ltr'Lg>l ttL>(WW I hercby affirm under penalty of perjury that I under provision of Chapter 9 (comrnencing with Section 7000) of Division 3 of the Business and Professions Code. and my licensc is in full force and effect. License hoto.f'nnlronlnr. W I hmby affim unda pcnalty of pqjury that thft is a cotrsructioD loding agacy for thc pcfommcc of thc worl for which this pqrnil is issucd (56. 3097, Civ. C.). lfids'sNme: Lender's Addless: APPLICANT DECLARATION I hereby aflirm under penalty of perjury one of the following declarations: Demolition Perrnits-Asbestos Notification Federal Regulations (Title 40. Parr6) -Required Letter of Notification t-l cenify that the federalregulations regarding asbcstos removalare nol applicable to this project. _l certi& that I have read this application and state that the is correcl. I agrc to comply with all City and County ordinances and Statc Laws relating to building representatives of this City and County to erter upon the above mentioned property for Applicant or Agent Perntitec niltne 6rf 0 16 -14 Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloor/VenUl nsu Iation Roof Sheathing Shear Wall Framing lnsulation/Energy Drtnruall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif I I n FINAL e \aIA pftry-5 7 Certificate of Occupancy I I Notes, Remarks, Etc. Carrier: License Number: