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SITE-WORK DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION I hercby affirm undcr pcnalty of pcrjury that I m cxcmpt frcm thc ContractoB' Liccnrc kw for the following rc&sn (Ss.?031/5 Busincss ard Profcssion Codc): Any City or County which rcquircs a frcrmit lo construct, altcl improvc. dcmlish or rcpair any structurc, lrior to its issuancc, als rcquires thc rpplicant for such lrcrmil to file a signcd statemnt that he or slrc is liccnrcd puunt to thc provisions of thc Conlractor's Liccn$d llw (Chaptcr 9. Commcrcing with Srction ?000 of Division 3 of thc Busincss md Pmfcssions Codc) or that hc or shc is cxcmpt lhcrcfron and thc basis for thc allcgcd cxcmption. Any violation of SNtk n 703 1.5 by any applicanl for a pcrmil subjcls thc arplicant to a civil pcnalty of not mrc than fivc hundrcd dolles ($500), _1. as owncr of thc propcrty. or my cmployees with wagcs as thcir solc comlrcnsation. willdo thc work and thc structurc is not intendcd or offcrcd for salc (Sec.7044. Busincss and hofessions Code: Thc Contractor's Licensc Lrw does not apply to an owncr of the proJrcrty who builds or improves thcrcon, and who docs such work himsclf or hersclf or through his or hcr own cmployccs. providcd that such ilnprovcrncnts are not intcnded or ol'fcred for salc. If, howcvcr. thc buildirrg or inrprovcment is sold within onc year of cornplction. thc Owncr Buildcr will havc thc burdcn of proving thal hc or shc did not build or improve the propcny for thc purynse of salc). -1. us owncr of thc propcrty. am exclusivcly contracting with liccnscd conlractors lo conslruct tlrc projcct (Scc. 7W, Busirtcss and Profcssion Codc: Thc Contractor's Liccnse Law docs nol apply to an owncr of progrcrty who builds or improves thcrcon, and who contracls for such projects with a Contraclor(s) liccnscd pursuant to thc Contractor's Licensc t aw). -IatncxcnrptundcrSection-,B.&P.C.tbrlhisrcason.I)atc: WO ITKERS' COM PENSATION DECLARATION I hercby aflrrn under penalty of prjury one of the following dcclarations: _l havc and will maintain a Certificate of Conscnt to Self-lnsurc for workcrs' compcnsation, as provided for by Section 3700 of thc Labor Code, fbr thc pcrfornuncc of thc work for which the pcrnrit is issucd. _l havc and will rnaintain workcrs' compcnsation insurance. as required by Scction 3700 of thc hbor Codc. for the pcrformancc of thc work for which this pcrmit is issucd. My workcrs' compensation insurancc carrier and policy number arc: .rr,"r. 4 a ,.6ar,., r n lrr, ", Et^r.e Cc Policy -6(:'[ go I -o I -lo't' la &Z _l ccrtity thal in the pcrformancc of thc work for which this Jrcrrnit is issucd. I shall not employ any person in any manncr so as to bcconrc subjcct to the workcrs' comlrcnsation laws of California, and agrce that if I should become subjcct to thc workcrs' compcnsation provisions of Section 3700 of thc l-atror Codc, I shall. forthwith cornply with those provisions. WARNING: Failure to sccurc workers' compcnsation coverage civil fincs up to onc hundrcd thousand dollars ($100.000). in Scction 3076 of thc [-abor Code, intercst and attorrrcy's fccs. is unlawt'ul. and shall an crnploycr to criminal Jrcnaltics and addition to the cost damages as provided for thc -3o-2ou I hcrcby altrrn undcr pcnalty of perjury lhat I anr liccnscd undcr Chaptcr 9 (commcncing with Scction 7000) of Division 3 of thc Busincss and Profcssions Codc. and my liccnsc is in t'ull lbrcc and cl'fcct. Licerrsc -A)Ll I hcrchy affirrn undcr pcnalty of prjury that lhcre is a construction hnding issucd (Sec. 3097, Civ. C.). for thc lrcrformancc of thc work for which this pcrmit is [.cndcr's Addrcss: APPLICANT DECLARATION I hcrcby affrm undcr penalty of prjury one of thc following declarations: Dcnrolition Pcrmits-Asbestos Notification Fcderal Rcgulations (Titlc 40. Parl6) -Rcqu ired l-cttcr of Notilication _l ccrtify that thc fedcral rcgulations regarding asbcstos rcmovalare not applicablc lo this projcct. _l ccrtify lhat I have rcad this applicatiorr and statc lhat the atnvc is corrcct. I agrcc to cornply with all City and County ordinanccs and Statc [:ws rclating to building represcntativcs of this City and County to cntcr upon thc abovc nrcntioncd propcrty for Applicant or Agenl Pernrileo name ard L) Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/Venvl nsu lation Roof Sheathinq Shear Wall t I ,t t -/U Framing ,/ll%lal Hluzh Ttlb^ lnsulation/Enersy qq/il46 t rleblat AE/bl tfia6/ Drywall E tu'la(rulh tr{6 Ext./lnt. Lath Brown Coat l\Iasonry Poo! Fence lL-./ -,4 T-Bar //7/r{/wtt{{4r1 trd Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif H I I .t / FINAL lullL(aat&z6s Certificate of Occupancv t I Notes, Remarks, Etc. BUILDING. INSPECTOR RECORD a trndcr's Namc: t+ J \