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BUILDING. !NSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DETTARATION I h@by amrtn utrd6 penalty of pqjury that I m cxcmpt liom the Contrado6' Lic@c Law for thc following reen (Sc.7031.5 Buinas od Profsion Codc): Any City or County which rcquiro a pcmit to coNtruct. altq, improvq dorclish or rcpeir oy structre. prior to its issuaca alm requir6 thc applicat for such pcrmit to lilc a signcd statmot thd hc or slrc b limed pwant to thc provisioru of the Contractor's Liccnsed Law (Chapt6 9. Commcncing with Setion 7000 of Division 3 of thc Busins ud Prcfe$ions Code) or that hc or shc is .xcmpt th@from ild lhc basis for thc allcgcd cxmption. Any violation of Sâ‚¬tion 7011.5 by ey applicant for a pemit subjats thc applicut to a civil penalty ofnot morc the fivc hundred dollm ($500). _1. as owner of the property, or my employees with rvages as their sole compensation. will do the work and thc structure is not intendod or offered for sale (Sec.7044, Business and hofessions Code: The Contraclor's License law does not apply to an owner of the propcrly who builds or improves thereon. and who does such work hirnself or herself or through his or her own employees, provided that such irnprovonents are not intended or offersJ for sale. If. however. the building or improvement is sold within one year of complaion. the Olvner Builder will have the h.uden of proving tha he or she did not build or irnprove the propoty for the purpose of sale). _1. as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7M4, Bwiness and Profcssion Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a Contractor(s) licensed pursuant to the Contractor's License Law). -l am excmpt under Section-, B. & P.C. for this reason. 0wner: WORKERS' COMPENSAT DECLARATION I hereby affrrm under penalty of perjury one of the follorving declarations: _l have and will maintain a Certificate of Consent to Sclf-lnsure for workers' compssation. as provided for by Section 3700 of the Labor Codc, for the performance of the work for which thc perrnit is issued. _l have and will maintain workers' compcnsation insurance. as required by Section 3700 of the tabor Codc. for the po'formance of the rvork for rvhich this pennit is issued. My workers'insurance carrier and policy number are: Policy _l certi& that in the perforrnance of the rvork for which this permit is issued. I shall not employ any pâ‚¬rson in any manner so as to bccome subject to the workers' cornpersation laws of California, and agree that if I should become subject to the workâ‚¬rs' compcnsation provisions of Section 3700 of the Labor Code, I shall. forthwith cornply with those provisions. WARNING: Failure to serure workers' compensation coverage is unlawful. and shall subject an onployer to criminal pcnalties and compensation. damages as provided for thecivil fines up to one hundred thousand dollars ($100.000), in to the cost of Section 3076 of the Labor Code, interest and attorney's- ,6-9.01 I hereby affinn under penalty of perjury that I arn licensed under provision 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full forcc and effect. ,/ License , c)o 3518 qq l).-r to'./ k)-o-2 r I hcby affm undo panalty of pcrjury thar th@ is a construclioo krditrg agmy for thc pqfomcc of thc worL for which this p6mit b isucd (Se. 3097, Civ. C.). ktrdfi's Nmc: Lender's Address: APPLICANT DECLATTATION I hereby aflirm under penalty of perjury one of thc following declarations: Demolition Permits-Asbestos Notification Fcderal Regulations (Title 40, Parr6) -Re4uiretl Letter of Notification _l cerrify that the fedtral regulations regarding asbestos removal are not applicable to this project.o -l certi& that I have read this application and state that with all City and County and County ,o ertter upon theordinances and State laws relating to above mentioned property for Applicnnt or Agent Permitee name (print): tt--â‚¬.) I Set Backs Forms/Stee!/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/Ve nUl n s u I atio n Roof Sheathing Shear Wall Framing lnsu Iation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif ), FINAL /A4.'?\lLc /st -t),uF57Al Certificate of Occupancy Notes, Remarks, Etc. _Expires: Date: