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BUILDING- INSPECTOR RECORD SITE.WORK DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION I hcrcby affrm undcr pcnalty of pcrjury that I m cxcmpt from thc Contraclor' Liccnre kw for thc following rca$n (Scc.7031.5. Busincss and Profcssion Cfllc): Any Cily or County which rcquircs r Frmil to construcl. allcl improvc, dcmlish or rqnir-uy slructre, lrior to its issuancc, also rcquircs thc applicant for such frcmil lo lilc a signcd statemnl thal hc or strc is liccn$d pursuant to thc tmvisions of thc Contractor's Lienscd t:w (Chaptcr 9. Commcrcing with Scction ?000 of Division 3 of thc Busincss and Prcfcssions Codc) or that hc or shc is cxcmpt thcrcfrom and thc basis for thc sllcgcd exemption. Any violation of Sstion ?03 1.5 by any applicant tbr a pcrmit subjccts thc applicant to a civil penalty of not mrc lhan five hundrcd dollus ($500). a _1, as owncr of thc prclErty, or my cmployccs with wrgcs os lhcir srlc o[[rcnsation. will do thc wort arxl thc stnrctrc is nol intcrdcd or ollercd for slc (Se.7O44. Busirrcss and hofcssions Codc: Thc Contraclor's Liccnsc [jw docs not apply to an owncr of thc pmlEny who builds or impmws thcmn. ard sho dds seh u)rk himrclf or her*lf or thrcugh his or hcr own employccs. pmvidcd that such impmrcmnts @ rcl intcrfu oroffcrcd for slc. tf, howcrci lhc buiHing or impmvcrcnl is sH within orc Far of onplction. thc Owncr Buildcr will harc thc burden of prcving that hc or shc dil mt buiH or iryrcrc the Jmpcdy for tlrc purJns of sh). _1. as owncr of the propcrty. am cxclusivcly contracting with liccnscd contrilclors lo construct thc prrtjcct (Scc. 7W, Busincss and Prrofession Code: Thc Contraclor's License Law does not apply to an owncr of property who builds or improves thereon. und who contfticts tbr such projccts with a Contractor(s) liccnscd pursuanl to thc Contractor's Liccnse Law). -lanrcxcn1ptunderScctiorr-'B.&P.C.ttlrthisrcason.Owner:- WORKERS' COMPF'NSATION DECLARATION I hcrcby affirm undcr pcnalty of pcrjury one of the following dcclarations: _l havc and will maintain a Ccrtificatc of Conscnt to Sclf-lnsurc for workcrs' compensation. as providcd for by Section 3700 of thc L-atyrr Codc. for thc pcrfornuncc of thc work for which thc pcrmit is issucd.IVl havc and will maintain workcrs' compcnsation insurancc, as rcquired by Scction 3700 of thc Labor Codc, for thc perlbrmancc of I[i work for which this pcrrnit is issucd. My workcrs' compcnsation insurancc carrier and policy nutrtbcr are: k\oLt,c. Poricy Nr-b"r, F,(lrlC,tt1fi U Expircs:G l.lLL -l ccrtify that in thc pcrfortErcc of thc work for which lhis JErmit is issucd. I shall not cmfrloy any pcrson in any mrcr m as to bccom subjcct to lhc workcrs'@mlrcnsation laws of California, and agre that if I should t$onE subjel lo thc workcrs'compcnsationpovisionsofscction3T00ofthctitnrCnlc,lshall,fonhwithcomplywiththospmvisions, WARNING: Failurc to wurc workcrs'compcnstion covcmgc is unlawful, and shall subjcct an cmploycr to cimiml [rcBllics Bnd civil fines up to onc hundrcd lhousmd dollus ($100,000), in addition lo thc cost of con{rcnsution, damgcs &s providcd for thc Scction 3076 ofthc tibor Codc, intcrcst snd attorrcy's fes. Date: LICENSEN CONTRACTOR NFCI ARATION I hcrcby atlirrn undcr pcnalty of prjury lhat I am liccnscd undcr provision of Chapter 9 (conrrncncing with Scction 7000) of Division 3 of thc Busincss and Profcssions Codc. and my liccnsc is in full frrrcc iutd cffctt. Liccnsc ctass: tt\J Liccnsc Numbcr:t o'Ll aqtt r)'rc: g ItXIt.ll W I hcrcby affrm undcr Fnalty of lErjury rhd thsc is a onstruction lcnding agcncy for the pcrfomncc of thc work for which this pcmil is issucd (Se.3097, Civ. C.). [,cndcr's Namc: lrnder's Address: APPLICANT NF'CLARATION I lrcrcby allirrn undcr pcrralty of pcrjury onc of the fbllowing dcclaratkrns: Dcrnolition Pcrrnits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40, Part6) -Rcqu ircd l.ettcr of Notification _l ccrtify that thc fcdcral rcgulalions rcgarding asbcstos rcnrovalarc not applicable to this pnrict. -{ r"rtitythat I have rcad this that thc atnvc intbrrnation is corrcct. I agrcc lo cornply with all City and County ordinances and Statc Laws relating to and hcrcby authorizc representativcs atxrvc mentioncd propcrty for Applicant or Agenl Pemilee nanre f(b Uul+- of this City and County to cntcr uJxrn thc Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenVl nsu Iation Roof Sheathinq Shear Wall Framinq lnsu lation/Energy Drywall Ext./lnt. Lath Brown Coat N/asonry Pool Fence T-Bar Handicap Req. Deputv Final Report Enqineer Final Report Flood Zone Certif /i ,4.. F!NAL '.tl [0 lzt f<il t"y Certificate of Occupancv t I Notes, Remarks, Etc. D