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BUILDING. INSPECTOR RECORD SITE.WORK DATE !D/SIG GOMMENTS OWNER BUILDER DELCARATION I haeby affm undo pcnalty of perjury that I m cxmpt from thc Conraclos' LiccN tiw for thc following rNn (Se.7031.5 Buines md Profsiotr Code): Any City or Couty which rcquirs a pcmh to constoct, alta, improvc, rhnolish or rcpair uy struc1ue. prior to its isumcc, also rcquir6 thc applicmt for such pcnnit to filc a signcd stalmmt that hc or drc b licmscd p$uet to the provisions of thc Contretor's Licmrcd l-aw (Chapter 9, Commencing with Strtion 7000 of Divbion 3 of thc Busincs md Prcfwions Codc) or that he or she is cx@pt th@from ud thc basis for thc allqgcd cxmption. Any violation of Setion 7031.5 by uy applicantforaparnitsubj*tsthe applicanttoacivilpemltyofnotmorcthilfivchundrcddollm($500). -1. as owner of the property, or my employecs with wages as their solc compensation. will do the work and the snrcture is not intended or offercd for sale (Se.7044, Business and Professions Code: The Contraclor's License [-aw does not apply to an owncr of the p,roperty who builds or improves thereon. and who does such work himself or hersclf or through his or her own cmployees. provided that such improvemcnts are not intcndcd or offerod for sale. I[, howerrcr. the building or improvemcnt is sold wilhin one ]&ar of complaion, thc Orvner Builder will have the burden of p,roving thd he or she did not build or improve the property for the purposc of sale). -1. as owner of the property, am exclusively contracting with licersed 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 Contraclor(s) licenscd pursuant to the Contraclor's License Law). _l am exempt undcr Scction-, B. & P.C. for this reason. Date: WORKERS' COMPENSATION DECLARATION I hereby affrrm undcr panalty of perjury one of the following declarations: -l have and will maintain a Certifrcate of Consent to Self-lnsure for workcrs' compensirtion, as provided for by Section 3700 of the Labor Code, for thc performance of the work for which the perrnit is issued. -l have and rvill maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance canier and policy number are: Ail;r*I l* irt^x.t ) ," icc 5 , lac. poricy N"^u-' cy'.IOOO 1O ZEZ0I Expires:,0'l-?Dzl _l certiff that in thc performance of the work for which this permit is issucd. I shall not onploy any person in any manner so ils to become subjcct to the workers' compensation laws of California, and agree that if I should bccome subject to the workers' compensation provisions of Secrion 3700 of the Labor Code, I shall, forthwith comply with those provisions. WARNING: Failure to sccure workers' compcrsation coveragc is unlawful, and shall subjcct an onployer to criminal pcnaltics and civil fines up to one hundred thousand dollars ($100,000), in addition to the cost of compensation. damages at providcd for the Section 3076 of the Labor Code, interest and attorney's fees. o*ez 3- 16'?o2l I hereby affrm undcr penalty of perjury that I am licensod under provision 9 (commencing with Section 7000) of Division 3 of the Busincss and Professions Code, and my license is in full force and effect. License Nurnber:n30 CONSTRUCTION LENDING AGENCY I hseby affm unds pcrulty of psjury that thqc is a congruction hnding agocy for thc tsfomcc of thc wort 6r which this pqmit is issucd (S*. 3097, Civ. C.). Lender's Name: Lender's Addrcss: APPLICAIIT DECLARATION I hereby affirm under pcnalty of perjury one of the following declarations: Demolition Permits-Asbestos Notification Federal Regulations (Title 40. Part6) -Required lrttcr of Notification -l cgriry that the fcdral regulatiom rcguding abctos moval rc not applicable to this prcjet. _l cdiry thar I havc rad this application md statc that the abovc infomaion is conet. I agre lo comply wilh all City ild Couty ordinilc6 ud State laws rclating to building coEtructiorl ard hwby authorizc Ep(Gatarivs of this City md County to otq upor the abovc mentioned propcrty for Appticant or Agent Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bfloo r/VenUI n su Iatio n Roof Sheathins Shear Wall Framinq Insulation/Energy Dryruall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif ,u FINAL lo lf l-l,t DWV fl Certificate of Occupancy Notes, Remarks, Etc. tu)9Laooficnnt: L/ Dilet 7- lt'aOZt Drrc, ,- 16'Z0z I