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I ELECTRICAL-INSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS Site-Work Underqround Pole Bases Liqht Standards Spas, Pool, Fountains Signs (monument) Life Safety /Low Voltage Fire Alarm / Dampers Communications Cable Buildinq Under Slab / Floor Bondinq I Groundinq I UFER Transformers Torqueing Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Roush) Ceilinqs (Hard & Soffit Rouqh Ceilinqs [-Bar Rouqh) Meter Release Rough /\ Service N/eter r\ FINAL l=---1-Zr\2 ,V,UZT Etc.'\-/ OWNE,R BI.'ILDER DIiI,CAIIA'TION I hereby affrnr under penalty of perjury that I anr exenpt from the Contractors' License l-aw for the following reason (Sec.7031.5 Busincss and Profession Codc): Any City or County which rcquires a pcrmit to construct, altcr, irnprovc, dcmolish or rcpair any slructure, prior to its issuance. also requires the applicant for such pernrit to file a signed staternent that lre or she is licenscd pursuanl to the pmvisions of the Contractor's l,icensed law (Chaptcr 9. Commencing with Section 7000 of Division 3 of the Busincss and Professions Code) or that he or she is exen4rt therefronr and the basis for the alleged exentption. Any violation of Seclion 7031.5 by any applicant for a pennit subjects the applicant to a civil penalty of not nxrre than five hundred dollars ($500). _1. as owncr ol'thc propcrty. or my cmployccs with wagcs as thcir sole compensation. will do thc work and the stnrcture is not inrerxlal or offered frrr sate (Sec.7Ma. Business and Pnrfcssions Codc: Tlrc Contractor's License l-aw docs not apply to an owner of the trroJrcrty wlm builds or improves therarn, and who does such work himself or herself or through his <lr her own entployees, providc.d that such improvcrncnts arc not intcrdcd or olTcred for sah. ll. hcrwcvcr, ttrc building or improverrcnt is sold within onc )tar of complction, tlrc Owner Buikhr will have thc burtlen of proving ttrat hc or shc did not buikl or improve Orc propcrty for thc purposc of sale). _1, as owner of the propeny, am exclusivcly contracting with licenscd contractors to construct ttrc proi:ct (Sec. 7044. Business and Protssion Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon. and who contracts fcrr such projccts with a Contractor(s) liccnscd pursuant to the Conuaclor's License Law). -l anr exempt under Section-, B. & P.C. tbr this reason. Date: Owner: WORKER"S' COM PENSATION DECLARATION I hcreby aftirm under pcnalty of perjury onc of thc following declarations: _l have anl will nraintain a Cerrilicate of Con.sent to Self-Insure for workers' conrgrcnsation, as pnrvided for by Section 3700 of the ##; for thc pcrlonnarrce of the work for which thc pcrmit ls issued. will nraintain workers'3700 of the l-abor Code, for the grcrfionrunce of which this ts iruxl prlicy nunrbcr arc: \] t2 D Policy _l ccrtify that in thc lrcrfornuncc of tlrc work for which this pernrit is issucd, I shall not cnploy any pcrson in any manncr so as to becomc subjcct to the workcrs' cornpcnsation laws of California. and agrec that if I should bccome subject to thc worliers' conrlrnsation provisions of Section 37fi) of the L:bor Code, I slull, forthwith conrply with those provisioru.. WARNING: Failure to secure workers' compensation coverage is unlawfiul, and shall subject an employcr to crirninal pcnaltias and civil tines up to one hurrdred thousand dollars ($100.m0). in addition lo the cost of compensation, danuges as provided fgr the attorncy's [ccs. \ I hercby affirnr under pnalty of perjury that I anr licenscd under provision of Chapter 9 (contnrencing with Section 7000) of Division 3 of the Business and Professions Code. arxl my license is in full forcc and efifect. (, License o ( CONSTRUCTION LENDING AGENCY I hereby alljrm under pcnalty of pcrjury that thcrc is a construction hnding agency for the pcrlbrmance of thc work lbr which this pcrmit is issued (Sec. 3097, Civ. C.). Lender's Naure: lrnder's Address: APPI,ICANT DECI,A RATION I lrrehy affrnr undcr pnalty of pcrjury onc of the lbllowing dc,clarations: Dcnnlition Pcrnrits-Ashcstos Notification Fedcral Regulations (Tillc 40, Part6) Rcquircd [-ctter of Notification /! ccrtify that the fcdcral rcgulations rcgarding asbestos rcmoval arc not applicablc to this projc.ct./ VI ccrtify ttrat I havc rcad this application and state tlrat the above information is correct. I agrc'c to conrply with all Cily and County ordinances and Statc laws relating to building construction, and hercby authorize reprcsentativcs of this City and County to entcr upon thc above rncntioned properly for inspection Applicant or Agent I'crmilce *,",,Wit{f )0 08-07-2015 t\ (