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ELECTRICAL.INSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNER B UII,DER DE,LCARATION I hereby affirnr under penalty of perjury that I anr exenpt fr<rm the Contractors' License [:w for the following reason (Scc.7031.5 Busincss and Prolbssion Crxlc): Any City or County which requires a permil to construct, altcr, irnprovc. dcmolish or rcpair any structurc, prior to its issuance. also requires the applicart for such Srermit to file a signed statefiEnt that lrc or she is licenscd pursuant to thc provisions of thc Contraclor's Liccnscd I:w (Chapter 9. Commencing with Section 7000 of Division 3 of the Business and Professions Code) or that he or slx is exenrpt therefrom and tlre basis for tlre alleged exentption. Any violation of Section 7031.5 by any appticant for a permit subjects the applicant to a civil pcnalty of not nrcre than five hundrcd dollars ($500). _1. a-s owner ot'the propcrty. or my elnployecs with wagcs a.s thcir solc compensation, willdo thc work and the stnrcturc is not interxtetl or offered for salc (Sec.7U4. Busincss and Profcssiorrs Code: The Contractor's Liccnsc Law docs not aPply lo an owncr of the proJrerty wlro builds or improws thereo& and wlxr dtxs suclr work himself or lrerself or through his or her own entployees, provided that such irnprovcmcnts arc nol intendcd or olfercd for salc. If, however, thc building or inprovcmcnt is sold within orc )tar of completion" the Owrrcr Buildcr will have thc burden of proving that he or she did not buikl or impmve fic property for thc purposc of sale). _1, as owner of the property, am exclusively contracting with licensecl conlractors to conslrucl thc project (Sec. 7(X4, Business and Prrofession Code: The Contractor's License Law does not apply to an owner of property wh<l builds or improves there<ltt, and who contracts for such projccts with a Contractor(s) liccnscd pursuant to the Contraclor's Liccnse Law). _l am exempt under B. & P.C. tbr this reason. I l^. ^. WORKERS' COMPENSATION DECLARATION I hc'rcby aftirm undcr Jrcnalty of pcrjury one of tlre lirllowing dcclarations: _l have ard will nraintain a Certilicate of Consent to Self-ln.sure for workers' compensalion, as provided for by Scction 3700 of the l-abor Code, for the pcrformance of the work lbr which thc permit is issued. _l have atrd will nuintain workers' conrpensation insurance, as required by Section 3700 of the l-abor Code, for lhe pcrfornunce of thc work for which this pcrnrit is issucd. My workcrs' compcnsation insurarrcc ciurier aml plicy numbcr arc: 9aH 6adCarrier: Policy l/r/rl _l ccnify that in thc lrcrfornuncc of tlrc work frrr which tlris pcrmil is issucd, I shall not cntploy any lrcrson in any manncr so as to become .subjcct to thc workcrs' conrpcrrsation laws of Califomia. and agree that if I should becomc subject to thc workers' conrpensation provisiorrs of Section 3700 of the Labor Code, I shall, forthwith conply with those provisions.. WARNING: Failure lo secure workers' comlrcnsation coverage is unlawful, and slrall subject an ernploycr to crirninal penaltias and civil fines up to one hundred thousantl dollars ($100.m0). in additi<ln to the c<lst of competsatiotl, danrages as pr<lvided for the Section 3076 of the [:bor Code, intcrcst and attorney's [ees. o^.u, lil'lt'Zol I hereby affirnr under penalty of perjury that I anr licensal under provision of Chapter 9 (comnrncing with Section 7000) of Division 3 of the Business and Professions Code. arxl my license is in full forcc ard effect. License Date: Number: ll.-lr-to f CONSTRUCTTON LENDING AGENCY I hereby affirm under pcnalty of pcrjury that thcrc is a construction lcnding agency for the performancc of thc work l'or which this pcrmit is issued (Sec. 3097, Civ. C.). [-cnder's Name: APPLICANT DECLARATION I My affrm unrler penalty of perjury one of the following declarations: Denrolition Permits-Asbestos Notification Fe<leral Regulations (Title 40, Part6) Required l-cttcr of Notification _I ccrtify thu the fedcral rcgulations regarding asbestos removd are not applicable to this project. I certify that I have read this application arxl state that the above infornration is correct. I agrec to conrply with all City and County ordinances and Statc l-aws rchting to building constructiorL and hereby auttxlrize representativcs of this City and County to enter upon ttrc above rEntioned property for Applicant or Pcrnritcc namc *,", ll'Klu Site-Work Underqround Pole Bases Lioht Standards Spas, Pool, Fountains Siqns (monument) Life Safety /Low Voltage Fire Alarm / Dampers Communications Cable Buildinq Under SIab / Floor Bondinq / Groundino I UFER Transformers Torqueing Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rouqh) Ceilinos (Hard & Soffit Rouoh Ceilinos [-Bar Rouqh) Meter Release Rough Service Meter )- F!NAL // tQf -Q)lz 04 vcle -25t7 Notes, Remarks, Etc. Flev. 08-07-201 5 qsrb7,