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BUILDING. INSPECTOR RECORD SITE-WORK DATE !D/SIG.COMMENTS OWNER BUILDER DELCARATION . LI rcLrcby affirm under pnalty of prjury that I am cxcmpt from thc Contractors' License [:w for the following reason (Scc.7031.5 Busincss and Profcssion Codc): Any City or County which rcquires a pcrmit to constnrct. altcr. improvc, demolish or rcpair any slructurc, prior to its issuance, also rcquircs the applicant for such permit to file a signcd statcmcnt that hc or she is licensed pursuant to thc provision.s of thc Contractor's Licensed l-aw (Chaptcr 9, Comrncncing with Section 7000 of Division 3 of thc Business and Profcssions Codc) or that hc or shc is excmpt thcrcfrom arxl thc basis for thc alhgcd cxemption. Any violation of Scction 7031.5 by any applicant for a pcrmit subjcrts the applicant to a civil penalty of not more than fivc hundred dollars ($5OOl. -1. as ownL*r of the propcrly. or nly cmpltryces with wages as thcir solc compensation. willdo lhc work and the stnrcturc is ncrt rntcndcd or ofl'crcd for sale (Scrc.7044. Business and Profcssions Codc: Thc Contractor's Liccnsc [:w docs not apply lo an owncr of thc propcrty who builds or intproves thcrmn, and who does such work hinnclf or hersclf or through his or hcr own employees. providcd that such improvcnrcnts arc not intendcd or offercd for sale. If. however, thc buikling or inrprovemcnt is sold within onc ycur of conrphtion. ttrc Owncr Buildcr will havc thc burden of proving that hc or shc did not buikl or improvc tlrc propcrty for thc purynsc of salc). -1. as owncr of the propcrty. am exclusively contracting with licensed contractors to construct thc projcct (Scc. 7W, Business and Profcssion Cr:dc: Thc Contraclor's Licensc Law does nol apply to an owner of progrcrty who builds or improvcs thcreon, and who contracts for such projects with a Grnlracto(s) liccnsed pursuant to thc Contractor's Licensc l-aw). _l am excrnpl undcr B. & P.C. for this rcason. i )irl t' ( )rr rrcl' WORKI'RS' CONT PI'NSATION DI'CLARA'I'ION I hcrcby affirrn undcr pcnalty of pcrjury one of thc following dcclarations: -l have and will maintain a Ccrtificate of Conscnt to Self-lnsurc for workcrs' compcnsation. as ;novidcd for by Section 3700 of thc [:bor Codc. for thc pcrformance of thc work for which thc pcrrnit is issucd. x havc and will maintain workcrs' compcnsation insurarrcc. as requircd by Scction 3700 of thc L:bor Codc. for thc performance of work for which this pcrrnit is issucd. My workcrs' compcnsation insurance carricr and policy nunrber arc: (fi|WftL I h/*lPtt't-â‚¬ urtYd{ Ptrlicy ltln, luz;t- _l cerrify that in the pcrf<rrmance of the work for which this perrnit is issucd. I shall not employ any pcrson in any nunncr so as lo bccomc subicct to thc workcrs' compcnsation laws of California. and agrcc that if I should bcconrc subict to thc workcrs' compcnsation provisions of Scction 3700 of the L:bor Code, I shall. forthwith comply with thosc provisions. WARNING: Failurc to lrcurc workers'compcnsation covcrage is unlawful. and shall subjcct an employcr to criminal pcnalties and civil fincs up to one hundrcd thousand dollars ($100.000), in addition to the cost of comgrcnsalion. damages as provided for thc .Scction 3076 of the l-:bor Codc. intercst and attorncy's ox",-4la{zrrn I hercby affurn undcr pcnalty of Jrcrjury that I am licensed undcr provisbn of Chaptcr 9 (comnrcncing with Scction 7Un) of Division 3 of thc Busincss and hofessions Code. and my licensc is in full force arxl cffcrct. Liccnsc B ctD Nurnbcr:0t orr", ?.lt u I hcrcDy affm urdcr pemlty of perjury thal tlw is I @nslruction letrditrg sgcrcy for thc pcrfomcc of the work for which thir [Emil is issc{ (Se. 3G)7, Civ. C.). hndcr's Narc: Lcndcr's Addrcss: APPI ICANT NECLARATION I My affinn under pcnalty of perjury one of thc following dcclarations: Dcmolition Pcrnrits-Asbcstos Notification Fedcral Rcgulations (Title 40. Part6) -Requircd lrttcr of Notification -l ccrtiry thar thc fcdcml regulations rcgedin8 a$cstos rcrmval rc ffn applicable to this pmj6t. _l ccnify that I havc rcad lhis application and stalc lhal thc atnve informtion is corccl. I agrc to cotrply vith all City and County ordinamcsardStatc[2wsrclatirgtobuiHingconslfftion andhcrcbyauthoriarcprcsntaliwsofthisCilyandCountytocnlc]ulnnthc abovc rrrcntioncd property for Applicant or Agent Pernritee nanle ox", tltuluu Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf Ioor/VenYI nsu Iatio n Roof Sheathing Shear Wall Framing lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat l\ilasonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif It r [,I n FINAL 0 r(L(WVJIA SffnD Certificate of Occupancy ll Notes, Remarks, Etc. Rev. 08-07-201 5