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SITE-WORK DATE ID/SIG.COMMENTS OWNER BT'ILDER DELCARATION <br />I hcrcby amrm undcr pcnalty of Frjury that I m cxctrrpt fmm lhe Contraclon' Liccns hw for thc followitrg rcen (Se.7031.5 ' <br />Business ard Prcfession Code): Any City or County which rcquircs a pcmit to @nstrut. slter, improvc. demlish or rcpair my <br />sttrturc, Irbr lo its issumc, also rcquircs lhe epplicml for such lEmit to filc o signd st0tcmnt thal lrc or slE ir liccnsd punuut ' <br />to the Fovisions of thc Contractor's Liccnred l:w (Chapter 9, Crmncing with Sction 70@ of Division 3 of thc Busiress md r <br />Prcfessions Code ) or that hc or she is cxcmpt thcrcfmm ard the bosis for thc allcgcd cxemption, Any violalion of Sction 7031.5 by any . <br />applicani for u Frmit subjEts the applicant to a civil pcmlty of nol mrc lhu fivc hundrcd dollus ($50O). <br />_1, as owncr of the propcrty, or my cmployecs with wagcs as their solc compcnsation, willdo thc work and thc stnEturc is not <br />intended or ofl'ercd for salc (Sec.7044. Business and Professions Codc: Thc Contractor's Liccnsc [,aw docs not apply to an owner of <br />the properly who builds or improves thcrcon. and who docs such work himsclf or hersclf or through his or hcr <lwn employees, <br />providcd lhal such impovcnrnts are not inlcndcd or offercd for salc. If. howewr, thc building or in{rroverrcnt is sold within onc }ryu <br />of conrplction. thc Owncr Builder will have tlre burdcn of proving thil he or she ditl not build or inqrrove the propcrty for tln purpsc of <br />salc). <br />-1. <br />as owncr of thc profrcrty. am exclusivcly contracting with licenscd contractors to construct thc proirt (Scc. 7W. Busircss <br />and hrlfcssion Code: Thc Contractor's License Law docs not apply to an owncr of propcrty who builds or improves thercon. <br />and who contracts for such projccts with a Contractor(s) licenscd pursuant to thc Contractor's Liccnse Law). <br />-IamcxcnrptundcrScction-.B.&P'C.forthisrcason. <br />f )ola. <br />WORKERS' COMPENSATION <br />DECL^RATION <br />I hereby affirm under pnalty of perjury onc of thc following dcclarations: <br />_l havc and will rraintain a Ccrtificatc of Conscnt lo Sclf-lnsurc for workcrs'comgrcnsation. as providcd for bySection 3700 of thc <br />l-,abor Codc. for the pcrformance of thc work for which thc permit is issued. <br />_l havc and will nraintairr as rcquircd by Scction 3700 of thc [:bor Codc. for thc pcrformarcc of <br />thc work for which this compensBtion insurancc carricr and Snlicy numbcr arc: <br />a <br />6 aPolicy <br />_l certity that in lhe pcrforrrmncc of thc work for which this pcrmit is issucd. I shall not employ any pcrson in any runncr <br />so as to bccome subjcct <br />workers' compcnsation <br />to thc workcrs'conrpensatiorr laws of Calilornia. and ifl to thc <br />provisions of Scction 3700 of thc [:bor Code, I <br />WARNING: Failurc to sccurc workcrs'compensation covcragc is crinrinul pcninltics arrd <br />civil fincs up to onc hundrcd thousand dollars (S100.000). in <br />Scction 3076 of the Labor Code, interest and attorncy's fccs. <br />as provided for thc <br />t <br />DECI.ARATION <br />I hereby affirm under penalty of perjury that I am liccnscd undcr provision of Chaptcr 9 (comnrcncing with Section 7000) of Divlion 3 <br />of the Business and Professions Codc. and my liccnse is in full force and cffcct.4License <br />/D <br />aDate:_ <br />W <br />I hcrcby alfrm undcr lEnally of Frjury that thcrc is I construclion lcnding agcrcy for the prforllrmc of thc work for which this Frmit is <br />iswcd (Se. 3097. Civ. C.). <br />Lrndcr's Namc: <br />Lcndcr's Address: <br />APPI ICANT NECLAILAT'ION <br />I hcrcby atlimr under pnalty of perjury onc of the following declarations: <br />Dcrnolition Pcrrnits-Asbcstos Notification Federal Rcgulations (Titlc 40, Part6) <br />-Rcquircd <br />lrttcr of Notification <br />lbdcral rcgulalions rcgarding asbcstos rcnnvalare not applicablc to this projcct. <br />read this application and with all City and County <br />and County to cntcr uflon thcordinanccs and Statc [:ws rclating to <br />above nrntioned property for inspection <br />Applicnnt or Agenl <br />Pernrilee nanre <br />o^r", ( ft*?-ow <br />Set Backs <br />Forms/Steel/Holdowns -7-Zl \MLU, <br />Erection Pads J <br />UFER Ground <br />SLAB Floor <br />S u bf loo r/VenVl ns u latio n <br />Roof Sheathinq -q''h <br />Shear Wall .{UAt tl <br />Framing i,sz)f 7-Ll J:IMN <br />lnsulation/Energy yAtil\ <br />D <br />rt lnt. Lath g .2 \lalln <br />B]6wn Coat <br />N/asonrv <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputv Final Report <br />Engineer Final Report <br />Flood Zone Certif . <br />I .? <br />FINAL \) <br />Certificate of Occupancy lt <br />Notes, Remarks, Etc. <br />(-I I,)t CovEr)1 t h Cri <br />,\-,*-L <br />I v@<t {l-d <br />-J \\V's <br />-i-fr:NT Qrv "\.\\\ <br />I -[-%l h €'\/ J <br />l- fr -'lo i s lritfit'rt\/ <br />il T \,\!1 !'.v\ <br />I <br />(/ <br />lznt V <br />2r15-A'i l <br />rl 0 <br />I <br />q-c )ryL \^l,i+/v -, <br />I <br />BUILDING. INSPECTOR RECORD <br />Rev. 08-07-201 5 <br />7 <br />\ <br />Ixt <br />t a <br />*fui p4]n,utu,;' ( <br />1 <br />) <br />a -'h. I <br />a <br />'Zr)'r <br />,l )fv /( <br />( )u ncr <br />oDate:_ <br />o <br />Contracto.. I