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BUILD!NG. INSPECTOR RECORD S!TE.WORK DATE ID/SIG.COMMENTS OWNERBUILDERDEI,CARATION - 'I hmby affim undo pcaalty of pcrjury thst I an cxcmp ftom thc Contracto6' Liccrc Law for thc following tlen (SE.7CJI.5 iBuinas ard Profasion Codc): Atry City or Counly which requira a po'mit to coNtruct. alt(, improvq danolish or repair oy structue prior to its issuocc. also rcquirc thc applicut for such pcmit to filc a signcd samot that hc or shc b lictred pwant to thc provisioE of thc Contractor's Liccnscd l:w (Chapta 9. Commcncing with Sation 7000 of Division 3 of thc Busins md Prcfe$ions Code) or that he or shc is cxempt thqefrom md the b6sis for the allegcd exmption. Any violstiotr of Setion 7031.5 by uy applicatforapemitsubjetsthe applicanttoacivilpcnaltyofnotmorcthefivehundreddollas($500). -1. as owner of the propâ‚¬rty. or my employees with rvages as their sole compensation. will do thc work and the structure b not intended or offered for sale (Sec.7044. Business and Professions Code: The Contractor's License larv does not apply to an owner of the properry who builds or improves thereon, and who does such wort himself or herself or through his or her own employees, provided that such irnprovanents are not intended or offâ‚¬red for salc. l[. howerrer. the building or improvement is sold within one year of cornpletion" the Orvner Builder will have the hrden of proving tha he or she did not build or improve the propoty for the purpose of sale). -1, as owner of the propcrty, am exclusively contracting with licensed contractors to construct the project (Sec. 7M4, Business and hofâ‚¬ssion 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) licensed pursuant to the Contractor's License Law). -l am exempt undcr Section-. B. & P.C. for this reason. WORKER.S' COM PENSATION DECLARATION I hereby affirm under penalty of po'jury one of the following declarations: -l have and witl maintain a Certificate of Consent to Self-lnsure for workâ‚¬rs' compensation, as provided for by Section 3700 of the L^abor Code. for the performance of the work for which the permit is issued. -l have and will maintain workers' compensation insurance, as rcquired by Section 3700 of the l-abor Codc. for the performance of the work for which this pcnnit is issued. My workcrs' compensation insurance carrier and policy number are: \rJCf toS., ca nC< poricy*,,*,- 34G<AO3( Expires: b lql l2o"-L -l certify that in the performance of the work fior which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers'compensation laws of California. and agree that if I should become subject to the rvorkers' compensation provisions of Section 3700 of the labor Code, I shall. forthwilh comply wilh those provisions. WARNTNG: Failure to secure workcrs' civil fines up to one hundred thousand Section 3076 of the Labor Code, interest compensation is and dollars ($100.000).the fees.klh*r Iq^ I hereby affrm under pcnalty of perjury that I am licensed 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code. and my license is in full force and effect. t c=-lo I0tq (co License Nurnber: Ur W I hrcby affm undo pemhy of pcrjury that thsc is a construclbn krding agocy for the psfomcc of the work for which this pqmh b issucd (Se. 3097, Civ. C.). [:ndo's Nme: Lcnder's Address: APPLICANT DECLARATION I horby aflinn under penalty of perjury one of the following declarations: Demolition Pennits-Asbestos Notification Federal Regulations (Title 40. Parr6) -Required Letter of Notification -l certi& that the federal re{ns regarding asbestos rernovalare not applicable to this project. _l certify that I have read this application and state that the above information is correct. I ordinances and State Laws relating to building construction above rnentioned property for Applicrnt or Agent Permitee hereby althorize 2r( Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloor/VenUl ns u lation Roof Sheathinq Shear Wall Framing !nsu Iation/Enerqy Drynruall Ext./lnt. Lath Brown Coat Nlasonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif rl ,t 0t F!NAL la\u A D'tVV ,-l Certificate of Notes, Remarks, Etc. l)alc: ,",", O8 l2t[/7o- I Puw a all City and County of this and County to enter upon the h,