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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNERBUILDERDE1CARATION { I hscby affm undq poalty of psjury that I en cxcmpt fiom thc Contrsclon' Licffi Law for thc following rcmo (56.7031:5 Busins md Prcfeion Codc): Any City or County which rcquiG a pqmit to @Ntruct, alto. imprcvq danolish or rcpair my structuc, prior to its isswcc. dm rcquirc rhc applicet for such lEnit to fih a signcd std@mt that hc or slE b ticdEcd ptNet to thc prcvisioN of thc Contrctor's Licascd taw (Chrptq 9. Commcncing with Satioo 7000 of Division 3 of thc Buins ud Prcfcsioro Code) or that hc or shc is cxmpt thqcfrom ild thc b6sis for thc allcgcd cxmption. Any violation of Setbtr 7031.5 by oy applicmtforapemirsubjctsthc applicuttoacivilpcnEltyofnotmorcthmfivchundrcddollus($500). _1. as owner of the propcrty. or my employecs with wagcs as their solc compcrsation. will do the work and the strLlcture is not interdcd or offered for sale (Se.7044. Busincss and hofessiors Codc: The Contractor's License l-aw does not apply to an owner of thc p,ropcrty who builds or improvc thcron. and who does such work himself or herself or through his or her own employees. provided that such improvonents are not intcndcd or oflbod for salc. If. howwer. the building or improvcfiiâ‚¬nt is sold within one )â‚¬ar of conplaiorL the Oryner Builder will have the burdcn of proving thd lre or shc did not hrild or improve the propoty for thc purpose of sale). _1, as owner of the property. arn cxclusively contracting with liccnsed contraclors to construct the projea (Sec. 7044, Buiness and Profession Code: The Contractor's Licensc Law docs not apply to an owncr of property who builds or improves thereon, and who contracts for such projects with a Contracto(s) licensed punuant to the Contractor's Licerxc l-aw). -l am exempt under Section-, B. & P.C. for this reason. I)q to' WORKERS' COMPENSATION DECLARATION I hereby affrrm under penalty of perjury one of the following declarations: _l have and will maintain a Certificate of Consent to Self-lnsure for workers' compensation. as provided for by Section 3700 of the Labor Code, for the perfonnance of the work for which the pornit is issued. _l have and will rnaintain 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' compensation insurance carier and policy number are: Carrier: Policy Number: Expires: _l certi& that in the performance of the work for which this permit is issuc<!. I shall not employ any person in any manner so ils to become subject to the workers'compensation laws of California. and agree that if I should become subject to the workers' compensation provisions of Sec-tion 3700 of the Labor Code. I shall. forthwith comply with those provisioru. WARNING: Failure to secure workers' compcrsation coveragc is unlawful. and shall subject an anployer to criminal panalties and civil lines up to one hundred thousand dollars ($100.000). in addition to the cost of cornpersation. da'nages as provided for the Section 3076 of the L^abor Code. intccst and attorney's fees. I hereby affrm under 3 of the Business and Professions Code, and my licensc is in full force and cffect. License Class: License Numbcr: CONSTRUCTION LENDING AGENCY I hcrcby a(fm udo pqulty of pffjury that thcc b a @nstrudbn landing agocy for thc psfomuce of thc rcrk br which this pqrnh b issucd (Sc. 3097, Civ. C.). Lender's Name: lrnder's Address: AIIIICANIDECIABAIIAN I tr&y a6nn unda pcnalty of pqjury onc of thc following dclsrstioru: Dcmolitiotr PmiB-Asb6tos Notificstioo Fcdml RclulatioE (Titlc 40, Parr6) -Rcquirâ‚¬d Lrttq of Notificalion -l cqtiry thal thc fcdsd rc8ulatioB rcgading abdtos moval uc not applicsblc to this prcj*1. -l cqriry rhat I bsvc Bd this application ad statc that thâ‚¬ 8bovc itrfomatioD is coE61. I 8gr to @mply with all City and County ordiMc6 ed Statâ‚¬ lrws relaing to buildiag coD$ructioE ild hmby authorirc Epr66tativ6 of this City ad Couty to otq upoo thc abovc motioncd prcpqty for i6pqlioD purpos6. Applicant or Agent Permitee name llo t o. Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/Ve nUI ns u latio n Roof Sheathing Shear Wall Framing Insu Iation/Enerqv Drlnruall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif I r-o FINAL l.lf+7r ,U ?7 b,AY>7 Certificate of Occu pancy I I Notes, Remarks, Etc. Contreclor:_