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BUILDING- INSPECTOR RECORD SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcrcby aflirm undcr lEnalty of pcrjury that I u crcmpt fmm thc ContractoB' Liccnsc Law for thc following rcaon (Sa.7031.5 Business uld Profcssion Codc): Any City or County which rcquircs a lErmit to construct. ahcr, imprcvc, dcmlish or rcpair my structurc, prior to its issuarcc. also rcquircs thc applicant for such lrcmit to filc a sigrcd statcmnt that hc or she h licenrcd puNilt lo thc prcvisions of the Contractor's Liccn*d Law (Chapter 9. Comcncing with Sfftion 7000 of Division 3 of thc Busincss and PrcfcssionsCodc)orthatheorshciscxemptthcrcfromsndthcb&sisforthcallcgcdcxcmption. AnyviolationofsctionT0Sl.5byany opplicont for a lEnnit subjccts thc applicanl to a civil pcnalty of not rcrc thu fivc hundrcd dolltrs (9500). -1. as owncr of thc propcrty. or my cmpk)yecs with wages as thcir sole compcnsation. willdo thc work and thc stnrcturc is not intcndcd or offered for sale (Sc.c.7M4. Busincss and Profcssions Code: The Contractor's Liccnse [:w does not apply lo an owner o[ thc proJrcrty who builds or inlprovcs thercon. and who docs such work himsclf or hcrsclf or through his or hcr own employces. providcd that such improvenrcnts arc not intcndcd or offcrcd for sah. lf, howcvcr, thc building or improvcnrcnt is sold within onc )rcsr of cornplction. thc Owncr Builder will have thc burdcn of proving that hc or shc did not build or improvc thc propcrty for the pur;nse of sah). -1. as owncr of thc proprty. anr exclusivcly contracting with liccnscd contractors lo conslruct thc projcct (Scc. 7W. Busincss and hotbssion Codc: Thc Contractor's License Law docs not apply to an owncr of property who builds or improves thereon, and who contracls for such projccts with a Contructo(s) liccnscd pursuant to thc Contraclor's Liccnsc l-aw). B. & P.C. for ?- I)IiCLA ItA'I'I()N I hcrcby aftjrm undcr pcnalty of perjury one of thc following dcclarations: -l have and will maintain a Ccrtificatc of Conscnt to Self-lnsure for workcrs' compensation, as providcd for by Section 3700 of thc Labor Codc. for lhc pertbrrnancc of thc work for which thc pcrrnit is issucd. -l havc and will rnaintain workcrs' compensation insurancc. as requircd by Scction 3700 of thc Labor Code, for the perfornuncc of the work for which this pcrmit is issued. My workcrs' compcnsation insurancc carrier arxl policy number are: Carricr:- Policv Numbcr: Exoires: -l ccrtify thal in lhc Jrcrfornunce of the work for which this pcrmit is issucd. I shall not cnrploy any lrcrson in any manncr so as lo bccomc subjcct to thc workers'comlrcnsation laws of California, and agrce that if I should bcconrc subject to the workcrs' comJrensation provisions of Scction 3700 of thc L-atnr Codc. I shall, forthwilh comply with thosr provisions. WARNING: Failure to sccurc workcrs' compensation coverage is unlawful. and shall subjcct an cmploycr lo crinrinal pcnaltics and civil lincs up to onc hundred thousand dollars (S1ffi.000). in to thc cost of cornpensation. damagcs as providcd for the Scction 3076 of Codc. intcrest and attorrcy's [ces. c.' DECI ARATION I hcrcby atlirrn undcr pcnalty of perjury that I anr licenscd undcr provision of Chapter 9 (conuncncing with Scction 7000) of Division 3 of thc Busincss and Profcssions Code. arxl my liccnsc is in full forcc and cffect. Liccnsc Class: Liccnse Numbcr: W I hcrcby aflirm undcr pcnultyof lErjury that thsc is a @nstruction bnding agcrcy for thc Frforroncc of thc work for which this Ismit is issucd (Scc. 3097. Civ. C.). lxndcr's Nam: Lcndcr's Addrcss: APPLICANT DECLARATION I hcrcby affinn undcr pnalty of perjury onc of thc following declarations: Dcrnolition Pcrmits-Asbcstos Notification Fcdcral Regulations (Titlc 40, Part6) -Rcquircd lrttcr of Notification -l ccrtily thal thc fcdcral rcgulati<lns regarding asbcstos rcnmvalarc not applicablc lo this projcct. -l ccrtify that I havc rcad this application and stale that thc atnve information is corrcct. I agrcc to corrtply , rcprescntativcs of this City wrth all City and County ordinanccs and Statc Laws rclating to building ufnn thc above nrcntioncd proprty for Applicant or Agent I'ernrilee name l^ and hereby authorize and /n Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bf loor/Vent/l n s u I atio n Roof Sheathinq Shear Wall Framing ?-l)-2 t D--â‚¬Ir- lnsulation/Energy Drywall Ext./!nt. Lath Brown Coat [\Iasonry Pool Fence T-Bar Handicap Req. Deputy Final Report Enqineer Final Report Flood Zone Certif. FINAL VID-71 g-{-9,2- Certificate of Occupancy Notes, Remarks, Etc. / Conlractor: