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APPROVALS DATE ID/SIG.COMMENTS OWNI'R B I' I I,DT:R DB:I,CA RATION <br />I hereby affinu under penulty of prjury that I anr exenlpt froru the Cbntraclors' License Law firr the filllowing, rea$lr (Sec.7031.5 <br />]lusincss and Prol'cssion Codc): Any City or Counly which rcquircs a Jrcrmit to construct, altcr. irnprove, dcrnolish or rcpair any <br />slructure, prior to its issuance. also ret;uires tlre applicant lirr suclr pnrill to fih a signed slatemenl that lre or she is licerr"sed pursuanl <br />to thc provisions of thc. Contractor's l,iccnscd l^aw (Chaptcr 9. Comrncncing with Scction 7000 ol'Division 3 of thc Busincss and <br />Prot'essions Ctde) or that lw or slrc is exenrpt tlrcrelionr and tlre basis for tlre alleged exentptiott. fury violation of Section 703 L5 by arty <br />lpplicant for u 1rcnnit subject.s thc applicant to t civil penalty of not nrore than five hundred dollars ($5mt. <br />_1. a.s owncr ol'tlr prolr-rt)'. or lny ctnplovccs with wagcs as thcir soL'cornfL-nsation, will do thc work and the structurc is not <br />ilttended or offeretl lor sale (Sec.70r]4. Business and Professions Cotle: Tlte Corrtraclor's License Law does not apply to an owner of <br />the pnrperty wlxr tr,rilds or in4rroves thcrurn, auxl wlxr does such work hinrself or herself or through his or her own entployees, <br />providcd that such irnprovcrncnts arc not intcnded or oll'crcd frrr sah. ll. howevcr. ttrc building or furpnrvcnrcnt is sold wilhin one ]t.lr <br />of completiorl the Owner Buikler will havc the burden of proving that lre or she did not buikl or inrprove tlr pruperty for the purpose of <br />sale). <br />_1. as owner of the property, anr exclusively contracting with licen.sed contraclors to construct tlr project (Sec. 7044. Business <br />alrd Pntlbssiorr Code: 'l'he Contractor's License Law drrcs not apply to anowner of property who builds or intproves thereott. <br />and who contracls for such pro.iccts with a Contractor(s) liccnscd pursuanl to trpL Conl.racl()r's Liccnsc hw). <br />-l <br />ant exetnpt uttder B. & P.C. lirr this reason. <br />lV( )RK F:RS' ('( )NI I'l;NSA',l'lON <br />I)ECLARATI0N <br />I hcrcby affirnt unrlc'r pcnalt.v of pcrjury onc o[ tltc tirlkrwing dcclarations: <br />_l have anl will nuintain a Certiticate of Consent to Selt'-lrrsure for workers' corr4rcnsation. as pruvided for by Section 3700 of the <br />Labor Cudc, for thc Jrcrforrnancc o[ the work lirr which tlrc pcrndt is issued. <br />_l have and will rnaintain workers' conrpensation insurance. as rcquired by Seclion 3700 of the [:bor Code, for lhe performarrcc of <br />tlrc work fbr which this lrcrnrit is issucd. My workcrs' con4rcnsation irsurance carricr and grolicy number are: <br />,.*rrr, ' EX € {l/l P+ <br />Poticy Number: i Expires: <br />a <br />_l ccrrity that in tlrc Jxrlirrnuncc of thc work frrr which this pcrrlit is issucd, I shall not cn4rloy any lrcrs()n in any nlanncr <br />so as to bccornc suhjcct to thc workL.rs' corupcnsation laws of Calil'ornia. and agrcc thut if I should bccotnc subject to the <br />workers' conrpensation provisions of Section 3700 of the Labor Cotle, I shall, forthwith comply with tlxrse provisions.. <br />WARNING: Failure to secure workers' contlrcnsation coverage <br />civil tirres up t() ()ne lrurrdred tlurusand dollars (S100.000t. in r <br />Scction 3076 of thc Latxrr Codc. intc'rcst and attorncy's t'ccs. <br />is unlawful, and shall subject an and <br />to tlre cost o[the <br />o,.".t lo-Ll -k) <br />I hereby affirnr under ;rcnalty of perjury tlrat I ant licertsed 9 (cornnrcncing with Section 7m0) of Division 3 <br />of the Business antl Profcssiorrs Code. and rrrv license is in l'ull force and effect. <br />License <br />D o <br />o*", 'l rr--Z 1 -7--1) <br />CONSTRUCTION LENDING AGENCY <br />I hcrcby al'lirrn undcr penalty of pcrjury that thcre is a construction lcnding agency for thc pcrlbrmancc of thc work l'or which this pcrrnit is <br />issuerl (Sec. 3097. Civ. C.). <br />Lender's Nanre: <br />Irrrdcr's Address: <br />APPLICANT DECLARATION <br />I Hryaffrmumlcr penalty of perjury onc of the following doclarations: <br />Denrolition Pcrmits-Asbcstos Notification Federal Regulations (Tille 40, Part6) <br />-Rcquircd <br />lctter of Notifrcation <br />_l ccrtify that thc fedcral regulations rcgarding a.sbestos removal are not applicable to ftis projct. <br />h/."nify that I luvc rea<l this application uxl statc thar ilre above information is correct. I agrce to conply with all City and Counry <br />drdf,ranccs and State Laws rclating to building constructioo ard hereby authorize representatives of this City and County to enter upon thc <br />above rrrcntioned propctly ftrr inspection <br />r\ ltlllicarrt ot' ..\genl <br />I't'rnrilec llanlc <br />Site-Work <br />Underqround <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Signs (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Buildinq <br />Under SIab / Floor <br />Bondinq I Groundinq I UFER lt l'7 DWry <br />Transformers <br />Torqueing <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilinqs (Hard & Soffit Rouqh <br />Ceilings (T-Bar Rough) <br />N/eter Release Iu lt?'7r0 )ftw>-/ <br />I <br />Roug h , <br />Service [Meter l,l l'7 '2a .bB3B / <br />FINAL tf:lTrE )ffi4 E <br />Notes, Remarks, Etc.r' I <br />+ <br />ELECTRICAL.INSPECTOR RECORD er <br />t <br />Rev. 08-07-201 5 <br />l)ete: <br />Arrrrlit'lnl: <br />Number: <br />tt1