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NO. a ADDRESS UNITS STORIES BEDRO�MS � CITY ZIP TEI. y DESCRIPTION SO.Ff: FACTOR PSF ADJ.AREANALUATION � OWNER-BCILOER DECI..ARATION � � SFRlADD/REM O [] 1 HEREBY AFFIRM UNDER PFIJPLTY OF PERJUflY THAT I AM EXEMPT FROM THE CANTHACTORS ll� �em�9/Ca({)On W CENSEUWFOflTHEFOLLpWINqREASON(SEC.7D31.SBUSMESSMIOPNOFESSIONSCOOE:ANYCIT'OA (n U COUN7YWFiICHHEWIRESAPEpMITTOCONSTHUCi,ALTER,YMVpOVE,OEMOUSN,ORREPAIRANYSTRUG W pg�lO/DBCk Z TURE.PPIOR TO ITS ISSUANCE.ILL50 REOUIRES 7HE MPLICAN7 FOR SUCH 7ERMIT TO flLE A SIONEO W STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRiICTORS lM w '- � � CENSEIAW(CHMTEA9(COAfNENCIN4WITHSECTION7Ib0}OFDIVISION30FTHEBUSINE55ANDPqQ V' POOVSpB ' FESSIONS CODE)OH THAT HE OR SHE IS EREMPT THEREFROM ANpTHE BASIS FOR THEALLEpEO EXEMP• V 710N.ANYVIOLATIONOFSECTION7037.6BYRNVAPPLICMfTFOqAPER1AI7SUBJECTSTHEAPPLiCANTTO � A9-Rpp} A qVIL PENALTY OF NOT MORE h1AN FIVE HUNDRED DOLNFS(S50o).): � � OI,ASOWNEROFTNEPROPERT;ORMVEMPLOYEESWITHWAOESASTHEIHSOLECOMPENSATWN, � (`,pmrtlBfC181 Wil,l DO THE WORK,ANO THE STHUCiURE IS NOT INTENDED OR OiFERED GOR SALE(SEC.70M,Bl1Sl• .� � NEs3 AND PROFES910N5 CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF PROPERT'WHOBUILDSORMPROVESTHEREON,ANDWHObOESSUCHWORKHIMSELFOHHER3ELFOR = � 7HNOUGHMISORHENOWNEMPIOYEES,PROWDEOTHATSUCH�IMPROVEMENTS%1pENOTYJT�NDED�R � � OFfEREDFORSALE.IFHOWEVER'MEBULL.pNGORIMPROVEMEl1'�ISSOIDWRIiINONEYEApbFCC1NPLE- Z TION,THE OWNER-6UIlDER WILL HI1VE'�ME BUR�EN OF PROVIN6 THAT HE OR SHE 010 NbT BUICU pR = NIPROVEFORTHEPURPOSEOFSALE). . W ❑I,ASOWNEiiOFTHEPROPEHTV,AME%CLUSIVELYCOMRACTINGWITNLICENSEOCQNTMdTOF/S � 70 CON57RUCT THE VRQIECT(SEC.70N.BU9INESS AND PROFESSIONS CODE:THE CONT�RACTqRS U� V81UA1i0f1 ADJ.AREA W CENSE LAW DOES NOTAPPLY TOAN OWtJEH OF A PROPERTV WHO BUILDS OR IMPROVE$YIVEREON,AND � WHOCONTRACT3FORSUCHPRQIECTSV/1THA[%M1Ta1CTdfi[S)UCENSEDPURSUANTTOTNECANTRAG (�UANTITY DESCRIPT1pN FEE TOPS LICENSE LAW.�. 0 °�yAM E7(EMP7 UNDEFl SEC. B.6 P.G.!UR THIS flEASON Q �. ✓ ` 1 _ LL � DATE OWNER U Z � UCENSED CONTRACTORS DECLARATION � � I HEREBV AFfIRM l/NOER PENALiY OF PERJURY TMAT IAM LICENSEL UNDER PAOVISiONS OF CHAPYER� � d e�COMMENCING WITH 5ECT10N 7000)OF�NISION 30FTHE BUSINESS AND PROFESfiIONS CODE,AND Z ?S MV LICENSE IS�N FULL FORCE ANO EFFECT. ,/ � UCBNSE CLAS _yrL'��t---�- LIQ NO. . � �G ' �� � V DATE CONTRAC7'bR d W . . _.... .. . .. � WOFKERS'COMPENSATION DEGLARA710N� U ;/ � IMEREBYAFFIqMUNOERPENALTVOFPERJURYONEOFTHEWLLAWINGDECLARATIONS: Z 2 lIHAVEMIDWILLMAINTAINACERTIFICATEOFCON5ENT70S�F-INSUREFORWORKER6' ��� � � �- Q COMPENSAT�ON,ASPROVIOE�BVSEC11IXJ37ooOFTHEtABOR CODE,FORTHEPERFOpMANC& W OF TXE WORK fOR Mhi1CH 7}fIS PERAtlT IS ISSUED. � � Q W _1HAVEANOWILLMAIN7NNWOfiKERS'C9MPENSATIONINSURANCE,ASREWIREDBYSECTION p 370o OF 7HE 1A80F CODE,FOR TNE PERiOqMANCE OF TNE WOHK FOR WHICH 7HI5 PERMIT IS ISSUED.MY WORNEflS'C@APENSATION INSURANCE CANRIER ANO POLICYNUM6ERARE: CONSTRUCTION �''`A�` Q r + � CARFIEp PU1N REVIEW .� zPouCYriuMBER ELECTRIC .¢ (iHISSECTONNE�NOiBE00MPLEf�OF1HEPERMtIS�ORCNEM.RAREODOLLARS(S10%OqlFSS). PLUMBING � �- � z I CERTIFV 7HAT IN 7HE PERFORMANCE OF7HE N�ORK fOR W WCH THIS PERIIIT IS ISSUED,I MECHANICAL °���a�� � 'l�-'} M[��' C3 SHAILNOTEMPLOYANYPER50NINANV MANNERSOASTOBECPMESUBJECTTpTHE � WORKERS'COM7ENSATIpNLAWSOFCALIFORNIA,ANOAGREETHATIFISHCW.DBECOME INSPECTIONFEE � SUBJECTTOTHEWOpKERS'COMPENSATIONDHOVISIONSOFSECTION97000FTHELABOfl . (� Oc%oqE i y�uF RTMWITMCOMPLYWI�Hyeqv�v����,; �SSUANCE p DA�`� � APPLICANT ��-�'/ SMIP J W ING:FAIU/RETOSECUREWONKERS'CAMPENSATIONCOVERA6EISUMAWFU4ANDSHµCBE ENERGYP/C LL SU`BJECTANEMPLOVERTOCRIMINALPENGLTIESANOCIVIIFINESUPTOONEHUNDR6DTHd1SANp ENERGYPERMIT DOLUNS(f100.000),W p�OiTION TO THE COSTOF COMPENSATION,DM/AGE3 AS PROVIDED FOR IN � SEC710N870BOFTMELABORCODE,IN7EREST,ANOA770RNEY'SFEES. RETENTIONFEE: d CONSTRUCTION LENDING AGENCY PqE-AlT FEE: O CC IHEREBYAFFIRMUNDEHVENALTYDFPERJUfiYTNAT7HEREISACONSiRUCTIONIENDIHOAGENCY d- FOq THE PERFORMANC6 OF THE WORK FOR WI{ICH THIS PERMiT IS�SSUEO(SEC.3007,dV.C.). W � LENDER'S NAME - �.... .... . �(�_ k, r 4 F�- LENDER'SAOURESS ..:.. •.�..�. ....� :;..;�..��.: � TOTAL FEES W ICERTIFY7HATIHAYEREAUTHISAPFLICATIONMDSTATETNATTHEABOVEMFORMATIONISCORREC7. Q IAOREETOCOMPLYN7TNALLC�TYANDCOUNTYOROINANCESANDSTATELAWSREU71N0TO9UIlpIN� � � CANS7RUC710N,ANDHEREBYAU7F/ORIIEPEPHESENTATNESOFTHISCOUNiY70ENTERUVONTNE � ABOyE-IIENt�PROPE FORINSPECTIONWRPOSES. COMMENTS o �r �-��'"��f� --' ,�e.. � � GE��E�(PRI� �} StGNANRE OF PEitMITTEE �� DATE ' � � � . . � � - � RECPT.NO. - � PAID BY ~� ��. VALIbATION " � � WHITE—Department Copy,YELLOW—Finence Copy,PINK—Assassor Copy,60LDENRQp--Flle Copyc GREEN—AppltcanYa Copy ^` Kc �ri .�xi,.,e�t '�Ly .a�:�.:,:� w�a,.:�1.� # .a„, s 171'{'.'.�,r'`�r.'M.5.-:t< r a7?*.�°,,Aa +rt`�'�T ��5:��""S .i's.�q.v� R"�, e. 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