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ELECTRICAL-INSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DI.ILCARATION I hereby affirnr under pcnalty of perjury that I am exetnpt from the Cbntractors' License l-aw for the following reason (Sec.7031.5 Busincss and Prolbssion Codc): Any City or County which rcquircs a pcrmit to construct, alter. irnprovc. demolish or repair any strucrure, prior to its issuance. a.Lso requires the applicant for such 5rcrnrit to file a signed slatemenl that he or shi is licensed f$rsuant lo thc provisions of thc Contractor's l,iccnscd law (Chaptcr 9. Commencing with Section 7000 of Division 3 ol'the Busincss and Professions Code) or that he or she is exempt therefrom and tlre basis for tlrc alleged exenption. Any violation of Section 7031.5 by any applicant for a pennit subjects the applicant to 0 civil penalty of not more than five hundred dollars ($5tttl). _1. as owncr ol'the propcrty. or my crnplovecs with wagcs as their snlc comgrcnsation, interxled or offered for sale (Ser'.7O14, Business and Professiorrs Corle: Thc Contraclor's willdo thc work and the structure is not , License Law does not apply lo an owner of the property wlxr builds or improvas therurrq and wlp dtrcs such work himself or lrcrself or througlr his or her own entployees, provided that such improvcrrcnts arc rnt intcndcd oroffcrcd for sale. Il. howcvcr, thc building or inprovenrcnt is sold within one year of comphtioru thc Owner Buiklcr will havc thc bunlen of proving ttut hc or she did not buikl or inprove Orc pnopaty for thc plrrpose of sale). _1. as owner of the propefly, am exclusively contracting with licenscd contraclors to construct thc projcct (Sec. 7044, Busines arxl hofessitxr Code: The Contractor's License Law dcrcs not apply to an owner of proprty who builds or inrproves thereon. and who contracts for such projccts with a Contracto(s) licenscd pursuant to tlre Contraclor's Licensc l-aw). -IantexemptunderSectitltt-,B.&P.C.fortltisreason. WORKE,RS' COM PI,NSATION DECLARATION I hc'rcby affirnr undcr pcnalty of pcrjury onc of tltc fbllowing declarations: _l have and will nuintain a Certilicate of Consent to Self-lnsure for workers' conrpen.sation, as pmvided for by Section 3700 of the Labor Code, for thc pcrfonnarrce of the work for which thc perntit is issued. /t#have alxl 3700 of the Labor Code, for the performance of work for iuxl lxrlicy numbcr iuc: 4 ( Eik,/'5 l) [Policy L _l ccrtify that in tlrc pcrlirrnuncc o[thc work f<rr whiclr this pcrmit is issucd, I shall not cnrploy any l)crson in any nlanncr so as to bccornc subject to thc workcrs' conrpcnsation laws of California. and agrce that if I stnuld beconrc subject to thc workers' conrlrcnsation provisions of Section 3700 of the Labor Code, I shall. forthwith conrply wilh thosc provisions.. a WARNING: Failure to secure workers' compensation coverage is unlawful, and shal! subject an employer to criminal penaljes and civil fines up to one hurxlred thousand dollars ($100.0(X)t. in addition to the cost of compersation, danrages as providedibr the Scction the latnr intcrcst and c r I hereby affirnr under penalty of perjury that I anr licenscd Chapter 9 (conmrncing with Section 7000) of Division 3 of the Bu.siness and Professiorrs Code. arxl my license is in full force and efifect. (, License 1 I hcreby al'lirrn undcr pcnalty issued (Sec. 3097. Civ. C.). CONSTRUCTION LENDING AGENCY of pcrjury that thcrc is a construction hnding agcncy for the pcrl'ormancc of thc work l'or which this pcrrnit is Lender's Nanre: APPLICANT DECLARATION I hercby affrm undcr penalty of pcrjury onc of the following declarations: Dcmolition Permits-Asbcstos Notification Fcdcral Regulations (Title 40, Part6) -Requircd l-ctter of Notificaton -l ccrtify that the fcderal regulations regarding asbestos removal are not applicablc to this pro]:ct. ,illn[*,fy rhat I have read this application and state that rhc above information is correct. I agrc.e to conrply with all Ciry and County -ordina\ccs and Starc l^aws relating to building constructioc and hcrcby auttnrize rep$:scntatives of this Cily and County to enter upon th above rncntioncd property for Applicant or Itcrnritcc nanre Site-Work Underqround Pole Bases Lisht Standards Spas, Pool, Fountains Siqns (monument) Life Safety /Low Voltaqe Fire Alarm / Dampers Communications Cable Building Under SIab / Floor Bondins lGroundinq / UFER Transformers Torqueinq Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Roush) Ceilinqs (Hard & Soffit Rouqh Ceilinqs [-Bar Rouoh) Meter Release Rough ,\ Service [Vleter I\ FINAL ll-7-n7r0 vhly1 1,1 Notes Remarks Etc. Rev. 08-07-201 5 will uraintain workers' which this lrcrnrit is issucd. , ) ,