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BUILDING- INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNTIR BUII,I)HR I)IiI,CARATION I hcreby affirnr under pcnalty of perjury that I am exempt from the Contractors' License [-aw for the following reason (Sec.7031.5 Business and Prol'ession Codc): Any City or County which requircs a Jrrmit to construct, altcr. itnprove, dcrnolish or rcpair any structure. prfurr to its issuance. also requircs the applicant for such permit to file a signed staternent that he or she is licenscd pursuant to the provisions of thc Contractor's Licensed law (Chapter 9. Commencing with Scction 7000 o[ Division 3 of the Business and Prof'essions Code) or that he or she ls exempt theretiom and the basis firr rlrc alleged exemption. Any violation of Section 7031 .5 by'any applic:rnt for a perrnit subjecls thc npplicant to o civil penalty of not more than five hundred dollars ($5tlO1. _1. as owncr ol'thc proprty. or rny crnployccs with wages as thcir solc compcnsation, will do the work and thc structure is not intendetl or offered for sale (Sec'.7014, Business and Professions Code: The Conlractor's License Law does not apply to an owner of the properly who builds or improves thereon, and who does such work hinxelf or hersell'or through his or her own employees, providcd that such irnprovc'ments arc not intended or ollcred for salc. Il, howcvcr. thc building or irnprovernent is soH within one ycar of conrpletirrrt, tlrc Owner Buildcr will havc thc burtlcn o[proving that lrc or she did mrt build or improve the prcpa'ty for thc purprsc of sale). -1. as owner of the property, am exclusively contracting with licensed conlractors to conslruct the project (Sec. 7(X4. Busincss arrd Pnrleskn Code: The Contractor's License Law does not apply to an owncr of property who builds or improves thereon. and who contracts for such projccts with a Contractor(s) liccnscd pursuant to thc Contractor's License kw). _l anrcxempt under Section_, B. & P.C. ltrr this reason. W( )RKI.IRS' C( )M l'],lNSA'l'l( )N DECI,ARATI0N I hcrc'by afl'irm undcr pcnalty of perjury onc ol'thc tbllowing rlcclaralions: -l have and will nrainlain a Certilicate of Consent to Self-lnsure for workers' comJrcrsalion, as provided for by Section 3700 of the Labor Codc. for the Jrcrformancc of the work lbr which thc permit is Lssued. -l have and will nraintain workers' conrJrcnsalion insurance, as required by Section 3700 of the [:bor Code, for thc lrcrfornunce of tlrc work filr which this pcrmit is issued. My workcrs' compcnsation insurancc carricr iuxl gllicy numbcr are: cuni,,. Z WKh Arntricern [ns C, Poticy Nunrter: ly' L CIb ] i[5] 000 Expires:o'l lorlzozI -l ccrrity that in thc prfbrnrancc ol'lhc work for which this pcrmit is issucd, I shall not cmploy any f,erson in any manncr so aslohccomesubjccttothcworkcrs'cornpcnsationlawsofCalifornia,arrdagrccthatil'lshouldbccomesubjecttothc workers' compensation provisions of Section 3700 of the Labor Cbde, I shall, forthwith comply with tlpse provisions. WARNING: Failure to sccurc workcrs' cx)mpcnsation coveragc Ls unlawful. and shall subject an employer to crimrnal pcnaltics and civil lines up to one hundred thousand dollars ($l(n.UX)), in addition lo the cosl of compensation. damages as providcd for the Seclion 3076 of the [:hor Cule, interest and attorrry's fees. D\rc. ob ( oe2 12, ?p I hcrcby al'lirrn undcr pcnalty of pcrjury that I arn liccnscd olChaptcr 9 (cornmcncing with Scction 7fin) ol'l)ivision 3 of thc Busincss and Protbssions Codc. aurd my liccnse is in full frlrcc and clfcct. l.icensc ctorr, t-q lozt I t72.1 lD2Y Liccnse Nurnbcr:O L(71o 1 oorc, o b/otf zaz o lZn,1 rr't,t d lt anrl linq S Ir h rrs-----r CONSTRUCTION I,ENDING AGT:NCY I hercby aflrm under penalty of perjury that thcre is a construction brrding agenLy for the performance of the work for which this pcrmit is issucrl (Sec. 3097, Civ. C.). Lendcr's Name: l-cntlcr's Atldrcss: APPLICANT DECLARATION I hcreby affrm under penalty of perjury one of the following declarations: Denrolition Permits-Asbestos Notification Fcderal Regulations (Title 40, Part6) _Required Letter of Notifrcation -l certity that the federalregulations regarding asbestos removalare not applicable to this project. -l certify that I have read this application arxl state that the above infornulion is correcl. I agree lo comply with all City and County onliltartces and State [-aws relating to building constructiorl arxl hereby authrrize representalives of this City and County lo enler ug)n ttE atxrve mcntioncd proFrcrty lirr inspcction Applicant or Agcnt l't rnrilee nanle oo,r, oc., rt? lZ tz a Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenVl nsu latio n Roof Sheathinq Shear Wall Framinq Insulation/Energy Drywall Ext./lnt. Lath Brown Coat lt/asonry Pool Fence T-Bar Handicap Req. Deputv Final Report Enoineer Final Report Flood Zone Certif FINAL W Certificate of Occupancv Notes, Remarks, Etc.A. ll Rev. 0B-07-2015 t ,