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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG COMMENTS OWNERBUILDERDELCARATION . T I hocby affrm unda poalty of pcrjury that I m qcmpt fiom thc Contraclom' Licffi kw for thc following r@n (Sc.7031.5 Bwincs and Profeion Codc): Any City or County which rcquirc a po'mit to @mtruct, alta, improvg dmolish or rcpair uy structuc, prior to its issuece, also requirG thc applicut for such pdrnit to filc s signed stalm@t that hc or $c b licqEd plmilt ro thc prcvisioru of the Cotrtretor's Licgscd L:w (Chapts 9, Commcing with Sctioo 7000 of Division 3 of thc Buine ud Prcfsions Codc) or that hc or shc is exanpt ths.from ud thc basis for thc allcgcd cxmpion. Any violation of Selbn 7031.5 by 8ny applicanl for a permit subjets thc applicut to a civil pcmlty ofnot more the livc hundred dollas ($500). _1. as owner ofthe prope(y, or my employees with wages as their sole compensation. will do thc work and thc structue is not intendod or offered for sale (Sec.7044, Business and Professions Code: The Contractor's Licerse law does not apply to an owner of the propo'ty who builds or improves thereon. and who does such work himself or hcrself or through his or her own employees, provided that such improvonents are not intcndcd or offered for sale. I[, hower/cr. thc building or imp,rovanâ‚¬nt is sold within onc ]ear of complaion, the Orvner Builder will have the burden of proving tha he or she did not build or improve the property for the purposc of sale). -1. as owner ofthe property, am exclusively contracting with licensed contracloni to construcl thc project (Sec. 7044, Business and hoftssion Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a Contracto(s) licanscd pursuant to the Contractor's Licanse l-aw). _l an exempt undcr B. & P.C. for orru,l0 - Q*2F71 I hereby alfirm under pcnalty of perjury one of the following -l havc and will maintain a Certificate of Consent to Self-lnsure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which the permit is issued. -l have and rvill maintain workers' compcnsation irsurancc, as required by Section 3700 of thc l-abor Code. for thc pcrformance of the work for which this pcrmit is issued. My workers' compensation insurance carricr and policy numbcr are: Carrier: Policy _l certi& that in thc pcrformance of thc work for rvhich this permit is issued. I shall not employ any person in any manner so as to become subject workers' compensation to thc workâ‚¬rs'com[rcnsation laws of California, and agree that if I should become subject to thc provisions of Section 3700 of the Labor Code, I shall,forthwith cornply with those provisions. . and shall subject an onployer to crirninal penalties andWARNING: Failure to secure workers' compensation coverage civil fines up to one hundred thousand dollars ($100,000), in Section 3076 of the Labor Code, interest and attorney's fees. is unlawful. addition to thc cost of compensation l4mages as provided for the o*",10 -'0f - 202,u_z I hercby affrm under penalty of perjury that I am licensod 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code. and my license is in full force and effect. License Nurnbcr: f):r I r.' W I heby affm unda pcoalty of pojury thal thqc is a congruction loding agocy for the pqfonMcc of thc wrt for which this pqmil b issucd (Sc. 3097, Civ. C.). Lender's Name: Lender's Address: APPI.I('A N'I' DT.]C LAITA'I'ION I horby affinn under penalty of perjury one of the following declarations: Demolition Permils-Asbcstos Notification Federal Regulations (Title 40, Pan6) - Required Lrtter o f Notification -l coti$r that the federal regulations regarding asbcstos removal are not applicable to this project. _l cenify that I have read this application and state that the above ordinances and State [arvs relating to building construction and above mefltioned propcrty for inspcction purposcs. Applicnnt or Permitee nnme orr", l0 - ol-P2( Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloo r/Ve nUI n s u latio n Roof Sheathinq Shear Wall Framinq lnsulation/Energy Drywall Ext./!nt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif. A I I ,/ FINAL lrl u>l ul ff|ff,>/ Certificate of Occupancy Notes, Remarks, Etc. _Expires: