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APPROVALS DATE ID/SIG.COMMENTS OWNTiR BUII,DIiR DEI,CARATTON I hereby affirnr under penalty of perjury that I am exenrpt frorn the Contractont' License [:w for thc following, reason (Sec.7031.5 Business and Prolbssion Code): Any City or County which requires a permit to construct, alter. improve, demolish or repair any structure, prior to its issuance. also requires tlre applicant for such pernit to file a signed slatenEnt that h or she is ticenscd pursuant to thc pmvisions of thc Contractor's Licenscd taw (Chapter 9, Commencing with Section 7(fi) of Division 3 of the Business and Professions Code) clr that he or she is exenpt therefrom and the basis for tlre alleged exemption. Any violation of Section 7031.5 by any applicant for a pennit subjects thc applicunt to n civil penalty of not more than five hundred dollars ($500). _1. as owner ol'the property. or my ernployccs with wages as thcir solL' compcnsalion, will do thc work and the stnrcture is not interxled or offerctt frrr sale (Scc.7H4. Business and Prufcssions Code: The Contractor's Liccnsc l-aw does not apply to an owner of the properly wlxr builds or improvr* thermq and wlro does such work himself or lrerself or lhrough his or her own enployees, provided that such improvelncnts arc not intendcd oroffcred for sale. Il. howcvct tlrc building or furprovenrcnl is soH within orc ),car of completioru the Owner Buildcr will have tb burtlen of pnrving thd tE or shc did not buikl or inprove Orc pnopaty for the purpose of sah). _1. as owner of the property, am exclusivcly contracting with liccnscd contractors to construct thc project (Sec. 7044, Busincss arxl Boftssion Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts lor such projects with a Contractor(s) licensed pursuant to thc Contractor's License l-aw). -l anr exempt under Section-, B. & P.C. for this reas<ln. f \,.. ^. WORKT]ITS' COM PE,NSATION DECLARATION I hereby affirm under pcnalty of perjury onc of the following dcclarations: _l have and will nnintafur a Certificate of Consent to Self-lnsure for workers'contpensation, as provided for by Section 3700 of thc I-abor Code, for the Jrerfonnance of thc work for which the Jrermit is issued. _l have and will maintain workers' conrpensalion insurarrce, as required by Section 3700 of the [:bor Code, for the perfonnance of thc work for which this pcrmit is issucd. My workcrs' conryrensation insurancc carrier arxl plicy numbcr are: Canier: Policy Numbcr: Expires: _l ccrrify that in thc lrcrfornrance of thc work for which this pcrmit i.s issucd, I shall not cmploy any pcrson in any manncr so as to becomc subjcct to the workcrs' compensation laws of California, and agrcc that if I should becomc subject to thc workers' cornlxnsation provisions of Section 3700 of the Labor Code, I shall, forthwith comply with thosc provisions.. WARNING: Failure lo secure workers'cornpensation coverage is unlawful, and shall subjcct an cmploycr to criminal pcnaltics and civil fines up to one hundred thousand dollars ($100.000). in addition to tlrc cost o[ competuation, danuges as provirled for the Section 3076 of thc labor Code. intcrcst and altorncy's [ces. LICEIISED CONTRACTOR DECLARATTON I hereby affrrn under ;renalty of perjury that I anr licensul untler provision of Chapter 9 (comnrncing with Section 7000) of Division 3 of the Business and Professions Code. and my license is in full force and effect. Licerrsc Number: n^r^. CONS'TRUCTION I-ENI)ING AGENCI' I hcreby allirm undcr prcnalty of pcrjury that therc is a construction lending agcncy for the pcrlbrrnancc of thc work lbr which this pcrmit is issuetl (Sec. 3097. Civ. C.). Lrnder's Name: APPI,ICANT DECLARATION I My affirm undcr pnalty of perjury one of the following declarations: Denrolition Pernrits-Asbestos Notification Federal Regulations (Title 40, Part6) Rcquircd lrtter of Notification _l ccaily that thc fcdcral rcgulations rcgarding asbcstos rcmoval arc not applicablc to this project. _l ccrtily that I havc rcad this application and statc that lhc abovc inlbrmation is corrcct. I agrcrc to contply with all City and County ordinances and State l-aws rclating to building construction, and hereby authorize reprcscntatives of this City and County to enter upon thc above rnentioned property for inspection purposes. Applicant or Agent Pcrmitec name (print): Site-Work Underoround Pole Bases Light Standards Spas, Pool, Fountains Signs (monument) Life Safety /Low Voltage Fire Alarm / Dampers Communications Cable Buildinq Under Slab / Floor ll Bondinq I Groundinq I UFER 6 'Ll 7!/DK{Y -/ Transformers I Torqueing Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rouqh)7 IN 40 DffW 7 Ceilinqs (Hard & Soffit Rouqh Ceilinqs (T-Bar Rouqh) N/eter Release a{%t\/f++4 fl Rough tl Service lVleter c 7rl 'u >(wt r/ FINAL ot lr '4, 11 n l>rq-**{ Notes, Remarks, Etc.r/ ELECTRICAL.INSPECTOR R ECORD Rev. 08-07-201 5 (,/