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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNERBUILDERDELCARATION . <br />I hcrcby omrm under pmlty of prjury thd I m cxcmpl from thc Contmctom' Licens liw for thc following rercn (Src.7031.5 <br />Busincss and Profcssion Codc): Any City or County which rcquircs s fErmit to construct, altc]. improve, dcmlish or rclEir any <br />structurc, prior to its issuucc, rlso rcquircs the applicant for such Frmit to lilc a signcd statercnt that he or she is lienrcd pmuaht <br />to thc Fovisions of thc ContEcror's Liccn$d hw (ChrpIcr 9. Commcrcing with Scction 70OO of Division 3 of thc Busircss ond <br />PmlcssionsCodc)orlhathcorshciscxcmptthcrcfromondthcbssisforthcallcgcdcxcmption. AnyviolationofscctionT03l.5byany <br />applicant for a lErmjt subjets thc applicant to a civil pcnalty of not mrc than five hundrcd dolltrs ($500). <br />-1. <br />as owncr of thc property. or my employccs with wagcs as thcir solc compcnsation. willdo thc work and thc stnrture is nol <br />intendcd or offcrcd for salc (Scc.7(X4. Busincss and hofcssions Codc: Thc Contraclor's Liccnse Law docs not apply to an owncr of <br />thc prcpcrly who builds or improvcs thcrcon. and who docs such work himsclf or hcrrclf or through his or hcr own cmployccs, <br />providcd lhat such improvcnrcnts arc not intcndcd oroffcrcd for sale. lf. howcvcr, thc building or improvcrrcnt is sold within one ycar <br />of complction. thc Owncr Buildcr will havc thc burdcn of proving lhal hc or shc did not build or irprove thc propcrty fur the purposc of <br />salc). <br />-1. <br />as owncr of the property. am cxclusively contracting with liccnsed contractors to construct thc project (Sec. 7W, Busincss <br />and Profession Code: The Contractor's Licensc Law docs not apply to an owner of propcrty who builds or improvcs thcreon, <br />and who contracls tbr such projccts with a Conlractor(s) liccnscd pursuant to thc Contraclor's Liccnsc [aw). <br />-IamexcmptundcrSection-'B.&P.C.forthisrcason.Il.rr,..1t.--^-. <br />WORKERS' COIVT PENSATION <br />DECI {RATION <br />I hcrcby affirm under ;rcnalty of perjury one of the fbllowing dcclarations: <br />-l <br />havc and will maintain a Certificale of Consent to Self-lnsurc for workers' compcnsation. as provided for by Scction 3700 of thc <br />work lbr which thc pcrrrrit is issued. <br />Scction 3700 of thc Labor Code. for the pcrfornrance of <br />,carrier and Jnlicy numhr are: <br />6 2 P.^Policy <br />_l ccnify that in thc lrrformns of thc work for which this lrcrmit is issucd. I shall not cmploy any JErson in any mrnncr <br />s as to bc@m subFct to Ihc workcrs' compcnstion laws of Califomia, and agrcc that if I should bccom subjcct to the <br />workcrs'compcnsationprcvisionsofSction3T00oflhctiborCodc, lslull.forthwithcomplyvilhlhosprcvisions, <br />WARNING: Failure to surc worke6'@mIEnsalion covcragc is unlawful. and shall subjct an cmploler to aimiml Fmltics and <br />civil lines up to onc hundrcd thousand dollaB ($100.000), in addition lo thc cost of comlrcnsalion, damges as provided for thc <br />Scctiorr intcrcst and allorrcy's fccs.b <br />I)llCl.r\lt,\'l'l( )N <br />I hereby atf irm undcr pcnalty of pcrjury that I am liccnsed undcr provision of Chaplcr 9 (comnrcncing with Section 7000) of Division 3 <br />of thc Busincss and Profcssions Code. and nry license is in full forcc and cffect.7('fffio <br />W <br />I hcrcby affirm undcr trcmlty of pcrjury thd thcrc is a constructk n bnding agency for thc pcrformncc of thc work for whkh this fsmit is <br />issucd (Scc. 3097. Civ. C.). <br />Lcndcr's Namc: <br />Lrndcr's Address:t <br />APPLICANT NECI ARATION <br />I hercby affrnn undcr penalty of perjury one of the following dcclarations: <br />Dcmolition Pcrmits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40. Part6) <br />_Rcquircd Lctter of Notification <br />County <br />abovc nrcntioned propcrty for <br />Applicant or Agent <br />I'ernritee nanre <br />pur[x)scs. <br />up,on thc <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenUI ns u Iation <br />Floof Sheathinq <br />Shear Wall <br />F[aming <br />lnsulatio nlEnerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />[Vlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />/9m L l/ +- at l1 I ., ,ln -d-e fu)a <br />FINAL ,/7U O. 7t 7v/2',Vtc.* //./ <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />-L <br />Exnires: <br />_ Contraclor:_ <br />l'cdcralrcgululions regarding ashcstos rcnxrvalarc not applicablc to lhis projcct. <br />and hcrcby authorize rcprcscntatives <br />rcad this