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NO. a ADDRESS UNI75 STORIES BEDROOMS = CI7Y ZIP_ TEL. cn � DESCRIPTION SQ.Ft FACTOR PSF ADJ.AREAfVALUATION ��, p� OWNER-BUILDER DECLARATfOh SFR/ADD/REM O I HEflEBY AFFlRM UP1pER P�NALTY OF PER,NflV THAT i AM EXEMPi FROM TNE CONTRACTDRS LI- i GaragelCatport W� CENSEL4WFORTNEFOLLOWING�REASON(SEC.70315BU5lMESSAN�PROFESSIONSCO�E:ANYCITYOR (n U.�� COUNTYWHICHREOUIRESAFERMITTOCONS'flUCT,ALiER,IMPROVE,CEMOLISH,ORREPAlRANYSTqUG W paliolDeck W'�; TUflE,PRIOR TO ITS ISSUANCE,ALSO FEQUIRES THE APPLICANT FOR Sl1CH PERlAIT TO FILE A 51GNEp w ' SiATEMENT THAT HE OR SHE IS LICENSED PURSUAN7 TO iHE PAOVISIONS OF THE CANTRACTORS L6 � CENQELAW(CHAPTER9(COMME,NCWG'WITHSECT70N7ooa)OFDIVI310N3OFTHE9USINESSANDPRO- LL' POOVSP3 � ' FESSIONSCODE)OFt7HATH60R5HE1SEXEMPTTHEREFflOMANOTHEBASiSFOfliHEALLEGEDEXEMP- �i ;U�' TDN.ANVVIOLATIONOFSECTiONI7031SBYANVAPPLfCAN7FORAPERPAITSUfiJECiST'HEAPPLICANTTO z RB-ROOf � AqVILPENALTYOFNOTMORETHWVFIVEHUNORED004LARS($5oa).�: OI,ASOWNcqOF7HEPpOP hTV,OFMVEMPLOVEESWITHSVAGESASTHEIRSOLECOAAP'cNSA7ION, ��, � Commercial - WILI DO TIiE WpRK�ANO THE ST�l1CTlfRE IS NOT MTEN�E�OF OFFERE�FOR SALE(SEC.]041,9U51� _1 ' NE59 AN�PROFESSIONS CODE:YHE'CONTRACTORS LICENSE LpW DDES NOT APPLY TO AN OWNER oF � PROPERTYWNOBUILDSORIMPRQVESTHEP.EDN,AN6WHOGOESSUCHWORKHIMSELFDRHERSELFOft m (L� iHROUGHH150RHEROWNEKMPLpYEES.PftOVIDEDiHAiSUCHIMPROVEMENTSARENOTIMEND_�OR L1J' OFFEREDFORSALE.jF,NOWEVER,17HEBUIL0INGORIMPROVEMENTISECLDWITHINONEYEAROFCOMP�E- . �'. ,TION,hIE OWNER-BUILDER WILL WAVE RHE BURDEN OF PROVMG THAT HE OR SHE DI�NOT BUILD OR � IMPROVEFORTNEPURPOSE�OF5pLE).' ��yy ❑I,ASOWNEROFTHEPROP�RiY,AMEXCWS�YELYCON7RACTINGWIiHLICENSE�CON'RACTOftS � i0 CANSTRUCT TH�PFQI'cCT(SEC.7oda.BUSINESS AND PflOFESSIONS CODE:7HE f.ONTRACTGRS Li� V8I1J841011 ADJ.AREA LL9 CENSEUlW00ESNCTAPPLYibANOWNEROFqPROPERTYWHOBUIL�50HIMPflOVESTHEREON,AND � 'WHOCONTRACTSFORSUCHPROJECTSWITHACONTRACTOR(S)LICENSEDPURSUANT707HECONTRAG QUANTITY DESCRBPTION FEE � T�RS LICENSE LAW,)�. �. o, ❑I AM EXEMPT UNDE�I SEC.���, B.&P.C.GOR iHIS R6ASON Q � U � � OAiE i '.ON?JER____ � � � � Z ij O LICEN ED CONTRACTORS DECLARATION -a 4 � W f'L IHEREBYAFFIRMUNDEflPENALThOFPERJURYTHATiAMLICENSCDUNDERPPOVISIONSOFCHAPTER � p:� 9(COAM�ENCING WITH S�CTION 70bo)OF DIVISION 3 OFTHE BUSINESS AND PROFESSIONS CODE,AND Z X: MY LICENSE IS IN FULL FOflCE AN EFFEC7 m LLI ��� Q LICENSE G 5 � � � LIG.NG.�¢I�� __'.1 � V' DATE'� I � CONTP,AGTOR.�L�-����SZ-.� � W L � WORKEqtS'GOMPENSATION DECLARATION Q ��'��� � U � IHEREBVAFFIqMI1NCERPENALTY��OFPERJUMONEOFTMEFOLLOWWGOECLAPNTIONS: Z /'��3� I v+" � _IHAVEANDWILIMAINTAIN�CEPTIFICATEOFCONSENTTOSELF-MSUREFORN'�RKEAS' 2 ^S'��a ��'�j�yC � COMPEN6ATION,ASPROVi EDBYSECTION370oOFiHELABORCO�E,FORTHEPERFORMANCE U 1 � � OFTHE WORK FOR WHICH HIS PERMI7IS ISSUE�. � 0 `'' I HAVE AND WILL MqINTAIN,wORKERS'GOMPENSATION INSURANCE,AS REQUIRED BY SECTION Q 37000FTHELABORCODE,FOPTHEPERFORMANCEOfTHEWORKFORWHICHTHISPEflMIT15 0 ISSUEO.MVWORiSEAS'COMPENSATIONINSU NCECARRIERANOP0.ICVNUMBERARE CONSTRUCTION Q' ]. cnAaiEa � '�:'�� _ PLANREVIEW � POLICY NUM6ER_� � �� �"�'� ELEC7RIC Q I Q� (fHISSECiIONNEmNOTBE(�MPL�TEDOFTHEPERMfrISWRONEHUNDREODOLLIRS($'COJoRLE55J. PLUMBING Ll� � I CERTIFVTHAT IN THE PER�ORMHNCE OF THE WORK FOR WHICFI THIS PERMIT IS ISSt/ED,I MECHANICAL .�, SHALL NOT EAIPLOYANW P RSON IN ANY MANNER SOAS TO BECOh9E SUSJECT TO THE � WORKERS'COMPENSATIOPILAWSOiCALIFORNIA, AGREETHA IFISHOU�OBECOME INSPECTION E � "�`A' '� � SUBJECTTOTHE'WORKER�y'COMPENSATIONPR IS NSOF IDN3�OOOFTHELABOF ���- - - . ._ � �, CO� ISHALL RTHWITHICOMpLYWIiNTHO P uFlO ISSUANCE � z-.1 t a.P��uctit�r. � SARIP � �" } a oare: —— . � � " ENERGY P/ WARNINO:FAILURETOSECUREWOpKERS'COMPENSATIONCWERAGEISUNLAWFUL,ANDSHALLBE I . `y SUBJECTANEMPI:�YERTOCRIMIN1ALPFNALTIESANDCIVILFiNESLPTOONEHUNDREDTNDUSAND ENERGYPE yo�_} DOlLARS(5I oo.DaO�.IN AD�I710N Ty THE COST OF COMPENSATION,DAMAGES AS PROVICEO'rOR IN — W STRW CST,AND ATTORNEY'S FEES. JS.. RETENTID J SECTION37080FiHELADOflCqOEi _' — �T� O CONI CT70N LENDING AGENCY PFlE-ALT FEE: -`� �' IHEREfiYAFFIRlAUN�EPPENAL7YOFPEktJUflYTHA7THEREISNCONSTRUCTIONLEN0INGAGENCY I ___,___ z FORTHE PEFWRMANCE OFTHE WbRK FOR WHICH THIS PERMIT IS ISSUED(SEC.3091,CIV.C.). � LL� S LENDER'SNAME � � � F-. LENDER'SAODFiESS � ICEPTIFYTHATiHAVEREADTHISAPPLiCATIDNAND5TATETHATTHEA80VEIN%ORMliIONISCORRECT. TO�AL FEEs7 �° � IAOREETOCOMPLYWIiHALLG'Y,ANDCO�'NTVOR�INANCESAN�STATELAWSREUTING708UILOING � CONSiRUCTION,AND,HEREBYAUTi-,ORIZE�EPR=SENTATIVESOFTHISCOUNiYTOENTE.9UPON'HE Z ABOVE-MEN710NEDPRDPERTYFOR'MSPECTIONPURPOSES. Q COMMEN7S _ ,�����. 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