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BU!LDING. INSPECTOR RECORD SITE.WORK DATE IDiSIG.COMMENTS OWNER BUILDER DELCARATION I hcrchy afiirm undcr lEnalty of lE]jury lhal I am cxcmpt liom lhc Contr.clos' Liccns kw lirr lhc lbllowing rcayrn (Sqi70.ll.s . Busincss afil Protbssion CuJc): Any City or Counly which rcquircs a JErmil kr drnslrucl. allcr. impruvc, rlcmolish rir rcpair any slructurc. pri)r to its issuancc, also rcquires thc applicant li)r such [Emit k tilc a signcd slatcmnl that hc or drc i{ liccnsd pursudnt b thc lmvisi()ns of thc Contrackx's Liccnscd hw (Chaptcr 9. Qommncing wilh Sation 7(xx) of Division -] of lhc Busincss and ProlbssionsCodc)orlhathcorshciscrcmltthcrcfromandthchrsisforthcallcgcdcxcmption. AnyviolationofSetionT0.!l.5byany applicaut for a pcrmit subjels thc applicant to a civil pcnally of not morc lhan fivc hundrcd dollus ($5Ur). _1. as owner of lhc pro;,crty. or my employces with wagcs as thcir sole compcnsation, will do lhc work and thc structurc is nol intcrrdcd orofl'crcd lirr salc (Sc--.7044, Business and Prof'cssions CrxJc: The Contraclor's Liccnsc Law docs not apply to an owncr ol' thc pfi)pcrty who builds or improvcs thcrcrrn. and who drrcs such work himsclf or hcrsclf or lhnrugh his or hcr own cmpkryces, providcd that such imprcvcrncnls arc not intcndcd or otlcrcd lirr salc. It, howcvcr, thc buihling ()r impK)vcnrcnt is solJ within onc ycar ol'comphtion, tr*h Owncr Buiklcr will havc thc burtlcn ol'proving that hc or shc did not buikl or improvc thc propcrty for thc purprsc of sah). r _1, as owner of the profrcrty, am cxclusivcly contracting with liccnscd contractors lo conslruct thc pnlject (Sec. 7M4, Busilrcss and ftotbsskrn Cor.lc: Thc Contractor's Liccnsc Law docs not apply to an owncr of proJrcrty who builds or improves lhcrcon, and who contracts lor such projccts with a Contractor(s) liccnscd pursuant to thc Contractrlr's Liccnsc Law). -IamcxcmptundcrScction-.B'&P.C.forthisrcason.Dale: Owner: 1VORKERS' CON I PENSATION DT:CI-ARATION I hcrcby atTirm undcr Jrcnalty ol'Jrcrjury onc of thc ttrlkrwing dcclarations: _l havc urd will mainlain a Ccrtil'icatc of Conscnt to Sclt-lnsurc tilr wrlrkcrs' comJrcnsati()n, as pnrvidctl tirr by Scction .1700 of thc Latxlr Ctxlc, lbr thc pcrlirrmancc of thc work tbr which thc Jrcrmit is issucd. _l havc anti will nraintain wrlrkcrs' compcnsation insurancc, as rcquircd by Scction .17([ ol'thc l-abor Cotlc, lbr thc Jrcrlilrmartcc ol' thc work lilr which this pcrnrit is issucrl. My workcrs' cotlrpcnsation insurancc camicr and Jxrlicy numhcr arc: Policy Number: Expircs: _l ccrtity that in thc Jrcrkrrmancc of thc work lilr which this Jrcrmit is issued, I shall not cmpkry any pcrson in any manncr so as lo bccomc subjcct t<l thc workers' comlrcnsation laws of Calilirrnia, and agrcc that if I should bccomc subjcct to the workcrs' comJrcnsation provisions of Scction 3700 of thc [-atxlr Crxlc, I shall, tbrthwith comply with thosc provisions. WARNING: Failure to sccurc workcrs' comJrcnsation c()vcragc is unlawful, and shall subjcct an cmployer to criminal pcnaltics and civil lincs up to onc hundrcd thousand dollars ($l00,Un), in addition to thc cost ol'comJrcnsation, damagcs as providcd ftrr thc Scctiorr 3076 of thc Latxrr Crilc, intercst and attorncy's l'ccs. Il.rt^. LICENSED CONTRACTOR DECLARATTON I herchy atlirm undc-r Jrcnalty of pcrlury that I am liccnrcd under provision of Chaptcr 9 (cornrncncing with Scctkln 7firu) of Division J o[ lhc Busincss anrl Pnllbssions Code, arxl my liccnsc is in full lorcc arxl cfl'cct. Liccnsc Class: Liccnsc Nunrbcr: W I hcrcby aflirm undcr Jrculty of Jrcrjury that thqc i\ a clrnstructi()n lcndiog agcrey for the Frlirmucc of lhc work for whtrh this Imit is issucd (Sec. 3097. Civ. C.). kndcr's Namc: I.crtdc'r's Atldrcss: APPLTCANT DECLARATION I lrcrcby atlirm undcr Jrcnalty ot'Jrcrjury onc of thc lirlklwing declarations: ficmolitron Pcrmits-Asbcstos Notit'ication Federal Rcgulations (Titlc 40, Part6) Rcuuircrl lrttcr ol' NotilicalrrnIt _l ccrtity that thc l'cdcnrl rcgulations rcgarding asbcstos rcntovalarc n()t applicablc to this pnrpct. _l ccrtify that I havc rcad this application and state with all City and County and County t0 enter uJxrn thcordinanccs and Statc [-aws rclaling to building abovc mcntioncd pnlpcrty lirr Applicant or Agent I)t nrrilce nanle lhc )Z Set Backs Fo rrn s/Stee l/H o ldown s Erection Pads UFER Ground SLAB Floor S u bf loor/VenVl ns u Iation Roof Sheathinq Shear Wall Framing Insu Iation/Enerqy Drywall Ext./lnt. Lath Brown Coat [/asonry Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif ,a FINAL 1o- 11 ."1 *fiLl Ul Certificate of Occupancy \-/ Notes, Remarks, Etc. .I 3 -a \,a.\ Flrrrr n9.-n7 -2n 1 6 Clarricr: Contractor: is