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BUILDING. INSPEGTOR RECORD SITE.WORK DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION t hrcby afftrm undcr pcnalty of pqjury that I m cxcmpt ftom thc Cotrtracton' Licse law for the following rwn (Se.7031.5 Busines arxl Profsion Code): Any City or County which require a pcmil to coNtrucl, dlq, improvq donolish or rcpair uy struc1rc prior to its issuocc. also requirB thc applicdt for such pennit to filc a signcd stal@6t that hc or shc is licosâ‚¬d pmuilt to the provisioE of thc Contractor's Liccnsed taw (Chaptq 9. Commcing with Sâ‚¬criotr 7000 of Division 3 of thc Bwins md PrcfesionsCodc)orthatheorshe iscxcmptthqellomudthebcisforthcallcaedcxmption. AnyviolationofScctionT03l.5byey applicaotforapennitsubjetsthc applicanttoacivilpcmltyofnotmorcthofivchun&eddollds($500). -1. as owner of the property, or my employees with wages as their sole compensation, willdo the work and the structure is not intcnded or oflered for sale (Sec.7044. Business and hofessions Code: Thc Contractor's Liccnse law does not apply to an owner of the propcrty who builds or improves thereon, and who does such work himself or herself or through his or her own employees. provided that such improvanents are not intended or ofFâ‚¬rerJ for sale. If, howe'ver. the building or improvenrent is sold within one )â‚¬ar of cornplaion. the Ourner Buildcr will have the burden of proving that he or she did not build or improve tlre propoty for the purpose of sale). _1, as ow'ner of the property. am exclusively contracting rvith licensed contractors to construct the project (Sec. 7M4. Business and Proftssion Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon. and rvho contracts for such projects with a Contracto(s) licensed pursuant to the Contractor's License [arv). -l arn exempt under Section-, B. & P.C. for this reason. WORKERS' COMPENSATION DECI..ARATION I hereby affirm under penalty of po'jury one of the following declarations: -l have and will maintain a Certificate of Consent to Self-lnsure for workers'compe{sation. as provided for by Section 3700 of the 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 Scction 3700 of thc Labor Code, for the pcrformancc of the work for which this permit is issued. My workers' compensalion insurance carrier and policy numbcr are: foJ*, I'olicy -l certi& that in the pcrforrnancc of thc work for rvhich this permit is issued, I shall not employ any person in any manner so as to becorne subject to the workcrs'compensation laws of California. and agrc.e that if I should become subject to the workers' compensation provisions of Section 3700 of the l-abor Code, I shall, forthwith comply with those provisions. WARNTNG: Failure to secure workers' compensation coverage is unlawful. and shall subject an onployer to criminal pcnalties and civil fines up to one hundred thousand dollars ($100,000). in addition to thc cost of compensation, darnages as provided for the Scrction 3076 of the Labor Code. interest and attorney's fees. I hereby aflirm under poralty 3 of the Business and Professions Code, and my license is in full force and effect. License Class: License Numbcr: I)rto' CONSTRUCTION LENDING AGENCY I hwby affrm undu pcnalty of perjury that thw is a comtruction lqrding agocy for thc pa fomcc of thc work for which this pamit is issued (Se. 3097, Civ. C.). Lender's Name: Lender's Ad&ess: APPLICANT DECLARATION I hercby affinn under penalty of perjury one of the following declarations: Demolition Permits-Asbestos Notification Fedcral Rcgulations (Title 40, Part6) -Re4u ired Latcr o f Notification -l ccfiiry that the fqlcal rcgulatiom rcgarding sbctos moval rc trot applicablc to this prcjer. -l cdiry that I have rad this applic&tion ed statc that thc abovc infomation is coret. I agrâ‚¬ to @mdy with all City and County ordinmcG ild Statc [2ws relating to building construcliorl od hqcby authorirc r.prGmtative of this City ud Couty to @tq upoD thc above mmtioncd prcpcny for iropc-tion purpos. Applicanl or Agent Permil$ nsmc (prlnl): Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/Ve nUI n s u latio n Roof Sheathinq Shear Wall Framing lnsulation/Enerqy Drywall Ext./lnt. Lath Brown Coat [/asonry Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif lt ,l ^a- F!NAL r0ltl lN Uwir&l 6 Certificate of Occupancy Notes, Remarks, Etc. Date:_