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INSPECTOR RECORD SITE-WORK DATE ID/SIG COMMENTS OWNER BUILDTR DELCARATION I hereby affirm under penalty of peqiury that I arn exempt form the Contractors' I.icense l.arv fcr the following reason (Sec.7031.5 Business and Profession Code): Any City or ('ountv u'hich requires a permit to corlstruct. alter. improve. demolish or repair any stnrcture. pior to its issuance. also requires the applicant for such prermit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor's l-icensed l.arv (Chapter t). ('ommencing rvith Section 70O0 of Division -1 of the Business and Professions Code) or that he or she is exernpt therefrom and the basis for the alleged exemption Any violation of Seclion 70.31 .5 by any applicant for a pennit subiects the applicant to a civil pnalty of not more than fir'e hundred dollars 1$.500). !-o f . .. owner of the property. or my employees rvith rvages as their sole comgrcnsation. rvill do the wort and the structurc is not intended or offered for sale (Sec.7044, Business and Professions Code: The Contractor's License law does not apply to an owner of the p,ropâ‚¬rty rvho builds or improves thereon. and who does such work himself or herself or through his or her orvn employees, provided that such irnprovements are not intended or offered for sale. If, howev'er. the building or improvement is sold within one year of complaion. the Owner lluilder rvill have the burden of prrrving that he or she did not build or improve the properw for the purpose of sale). N! t. as owner of the property. am exclusively contracting with licensed contractors to construct lhe project (Sec. 7044. Business and Profession ('ode: The ('ontractor's l.icense l.aw does not apply to an owner of properly who builds or improves thereon, and rvho contracls for such projects rvith a ('ontracto(s) licensed pursuant to the Contractor's [,icense l-aw). No I u* exempt under Section B. & P.C. for this reason. }VORKFR.S' COMPFNSATION NFCI dRATION I hereby affirm undet penalty of perjury one of the following declarations: !-t n.*'. and u'ill maintain a Ccrtificare of Consenr to Self-trsure for rvorkers' compensation, as provided for by Section -1700 of ttrc Labor Code. for the performance of the work for rvhich the perrnit is issued. NO _lhaveandrvill nraintainrvorkers'compensationinsurance.as requiredbySection.lTfi)ofthelaborCode.fortheperformanceofthc rvork for which this permit is issued. My rvorkers' compensation insurance carrier and policy number are: rtatc fund Carrier: 904350'l Policy'Nurnbcr: 01t01t2022 I:rpires: YES I cerrify thal in the perforrnance of the rvork for rvhich this pennit is issued. I shall not employ any person in any mannâ‚¬r so as to become suh.ject to lhe u,orkers'compensation larvs of California. and agree that if I should become subiect to the workem' compensalion provisions of Section .i700 of the Labor Code. I shall. forthwith comply with those provisions.. \l'ARNIN(i: Failure lo secure rvorters'compensation coverage is unlarvful. and shall subiert an employer to criminal penalties and civil fines up to one hundred thousand dollars ($100.000). in addition to the cost of compensation. damages as provided for the Section -1076 of the Labor Ccxle. interest and attomey's fees. LI('FNSFN ('ONTRACTOR NT('I dR.ATION I herehy alfinn under Jrenalty'of per.iury that I am licensed under provision of Chapter 9lcommencing with Section 7000) of Division .1 of the Business and Professions Code. and mv license is in frrll force and effect. c3e [,icense Class: G94940 l-icense Nurnher CONS'tRT'C'I'ION LEN DIN(; AG ENC }' I hereby alTinn under penalty of peliury that there is a construction lending agency for the performance of the work fior which this permit is issued (Sec. .1097. ('iv. C.). I-ender's Narne: l,ender's Adclress: APPLICANT NF('I ARATION I heretry atlimr under penalN of per;ury one of the followrng declaratrons Denlolrtron Perrnrts-Ashe$os Nolrficatron Federal Regulatrons (Trtle 40. Parl6) [o_ Required l-etter of Notilication t-t1 f cerrify that the federal regulations regarding asbestos removat are not applicable to this pro.iecr. t=t f cefliS/ that I have read rhis application ancl state that the atnve infonnation is correct. t agree to comply with all City and County ordinances and State l-arvs relating to building construction. and ha'eby authorize representatives of this City and Clounty to enter upon the above mentioned property for inspection purposes. Reroof "ll Roof (Diaphragm Sheathing/Frame)b tL1/,zt Kl4 -I-I O Structural Final Bln/u X^;I5X )? Plumbing I \-'7 Under Floor I Under Slab Rough Shower Pan / Tub Test Water Service Sewer / Sewer Cap Gas Air Pressure Test Plumbing Final Electrical Service (Meter I Panel) Grounding / Bonding Rough Electrical Final Mechanical Gas Air Pressure Test Rough Piping (HW, CW, etc.) Exhaust Ducts Mechanical Final Notes, Remarks, Etc.