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SITE.WORK DATE ID/SIG.COMMENTS Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloor/VenUl n s u Iatio n Roof Sheathing Shear Wall Framing lnsulation/Enerqy Drlnryal! Ext./lnt. Lath Brown Coat Masonry n,/ Pool Fence .$v/ T-Bar \ Handicap Req \ Deputy Final Report Engineer Final Report Flood Zone Certif nl F!NAL qt hl'tl PVqr,I Certificate of Occupancy Notes, Remarks, Etc. OWNER BUILDER DELCARATION I hereby allim under penalty of pcrjury thal I m cxâ‚¬mpt from thc Conftactoo' Licsc lrw for thc followitrg rcen (56,?03 1.5 BusinBs ad Profcsion Code): Any City or County which rcquirc a pamit to coNtocl, alto, improvq &molish or rcpair uy stoctuc, prior lo its isumcc, also require thc applicat for such pernit to filc 8 signcd statm@t tha hc or $c b licoscd pumt to thc prcvisions of the Contractor's Liccnscd [:w (Chaptq 9, Comcncing wilh S*tion 7000 of Division 3 of thc Buins ud Profcsions Code) or that he or she is cxempt thsefrom ild thc basis for the allegcd cxmption. Any violation of Sdion 7031.5 by uy applicantforapomitsubjetsthc applicanttoacivilpmltyofnotmorcthmfivchundrcddollm($500). _1. as owner of the property. or my ernployees with wages as their sole compensation. will do the work and the stnrclure is not intended or offered for sale (Sec.7044. Busincss and Professions Code: The Contractor's License [-aw does not apply to an owner of the propcrty who builds or improves theron, and who docs such work himself or herself or through his or her own employees. provided that such improvanents are not intended or offerod for sale. lf. horvwer. the building or improvanent is sold within one year of completion. thc Orvner Builder will have the hrden of provirry that he or she did not build or irnprove the p,ropo'ty for the purpose of sale). { -1. as owner of the property. am exclusively contracting rvith licensed contractors to construct the project (Sec. 7044. Buiness and Profession Code: The Contractor's License [,aw does not apply to an owner of property who builds or improves thereon. and who contracts for such projects with a Contracto(s) licensed pursuant to the Contractor's License Law). -l am exempt under Scction- . B. & P.C. for this reason. Date:-- $ WORKERS' COITPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: _l havc and will maintain a Certificate of Consent to Self-lnsurc for rvorkers' cornpensation. as provided for by Section 3700 of the -tzbot/Codq for the pqfomcc of thc wort for which thc pamh b issued. .Xo"" -a *itt .aintain workm' compcmatiotr ircurucq s requircd by Setion 3700 of thc Labor Codc, for thc pqfomcc of thc work for which this perrnit is isucd My workc' compcnsaion irouuce wiq aod policy numb6 flc: / Canier:14- __l certi$ that in the performance of the work for rvhich this permit is issued, I shall not so as to become subject to the workers' compensation laws of California, and agrec that if I employ any pcrson in any manner should become subject to the rvorters' cornpensation provisions of Section 3700 of the Labor Code. I shall, WARNING: Failurc to serure workers' compersation coverage is unlawful. forthwith comply with those provisions. and shall to civil fines up to one hundred thousand dollars ($100.000). in addition to Section 3076 of the interest and attorney's fees. q I I hereby afiirrn undcr penalty of perjury that I arn licensed with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. b Nurnber:Qitlo-7 'n CONSTRUCTION LENDING AGENCY I hercby aflirm unde pcnalty of pojury that th6c is a comtrucrion lading agocy for thc pafommce of thc work for which this pqrnit is issued (Se. 3097, Civ. C.). Lender's Name: Lendcr's Address: APPLICANT DECLARATION I hodry affirm under penalty of perjury one of the following declarations: Demolition Permits-Asbestos Notification Fcderal Regulations (Title 40, Part6) _Required Letter of Notification are not applicable to this projcct. I agree to compll'with all City and County of this Citl'and County cnter upon the 7*tpplicant or Agent 7,1- \e.mitee nome LL q BUILDING. INSPECTOR RECORD C,^r/ \ Policv Number:\f5t) ^r Liccnse;"-x_ - -a \ \t