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ELECTRICAL-I NSPECTOR RECOR D APPROVALS DATE ID/SIG.COMMENTS OWNI'R BUILDER DEI,CARATION I hereby affrnr untler penalty of perjury that I am exempt front the Contractors' License l-aw for the following rcason (Sec.7031.5 Business and Prolbssion Code): Any City or County which rcquircs a pcrmit to construct, altcr. irnprovc. demolish or rcpair any strucrure, prior to its is.suance. also requires the applicant for such grernrit to file a signed slaterEnl that lr or shc is liccnscd pursuanl to the provisions of thc Contractor's Licenscd Law (Chaptcr 9, Commencing with Section 7fiX) of Division 3 of thc Business and Professions Code) or that he or she is exem;rl therefrom and tlrc basis for tlre alleged exenption. Any violation of Section 7031.5 by any applicant for a pennit subjects the applicant to a civil pennlty of not rnorc than five hundred dollars ($500). _1. as owncr ol'the propcrty. or my crnployces with wages as thcir sole compcnsation, willdo thc work and thc structure is not interxlcd or offered for sale (Sec'.7044. Business and Profcssions Codc: The Contractor's License Law does not apply to an owner of the Jxogrerty wlro builds or irngrroves therarrl and wllo dtrs .such worlc himself or lrerself or lhrough his or her own entployees, provided that such improvenrnts arc rrlt intcnded or olTercd for salc. lf. hcrwcvcr, thc building or funprovcnrcnt is sold within one )tar of comphtion, the Owrrcr Builder will have the burden of proving that lre or she did not build or improve the propcrry for the purpose of sale). I. as owner of the propeny, am exclusively contracting with liccnscd contraclors to conslruct thc project (Scc. 7044, Business arxl hofession Code: The Contractor's License Law dtxs not apply to an owner of proJrcrty who builds or improves thereon. and who conuacts for such projccts with a Contractor(s) licenscd pursuant to the Contraclor's License taw). -IanrexemptunderSectiorr-,B.&P.C.lbrthisreason. WORKERS' COMPENSATION DECLARATION I kreby affirm undcr pcnalty of pcrjury onc of tlre tbllowing dcclarations: _l have and will nr,aintah a Certilicate of Consent to Self-Insure for workers' comperxation, as provided for by Section 3700 of the Labor Codc, for thc grcrfonnancc of the work lbr which thc perrnit is issued. _l have arrd will nraintain workers' conrpensation insurance, as required by Section 3700 of the l-abor Code, for the pcrfornnnce of thc work for which this 1rcrmit is issued. My workcrs' conrpensation insurancc caricr and gxllicy numbcr arc: Policy Number: Expires: _l certify that in thc lrcrfornunce of thc work for which this permit is issucd, I shall not cmploy any pcrson in any manncr so as to becornc suhjcct to the workcrs' conrpcnsation laws of California. and agrce that if I should becorne subject to the workers' cornpensation provisions of Section 3700 of thc Labor Cbde, I shall, forthwith c<lnrply with thosc provisions.. WARNING: Failure lo secure workers' compcnsation coverage is unlawful, and shall subject an employer to criminal penaltias and civil fines up to otrc hundred thousand dollars ($100.m0). in addition to the cost of competsation, damages as provided for the Scction 3076 of thc l-atnr Codc. intercst and attorncy's l'ccs. )\ I hercby affirnr under penalty of perjury that I artr pruvision 9 (corrrnrcncing with Section 7000) of Division 3 of the liusiness and l'rcfessiorrs Code. and rny in full force and effect. License I hcreby allinn undcr pcnalty ol'pcrjury that thcrc is a construction lcnding agcncy issued (Sec. 3097. Cir'. C.). pcrlbrrnancc of thc work ltrr which this pcrmit is l,cnder's Nanre: [rnder's Address: APPI,ICANT DECLARATION I ffiy affrm under penalty of perjury one of the foUowing declarations: Denrolition Pernrits-Asbcstos Notification Federal Regulations (Title 40, Part6) -Required lrtter of Notification _l certify that the fcderal regulations rcgarding asbestos rennval are not applicabh to this proirt. -.- I certify that I luve rcad this application ud state tlut ttre above infonnation is correct. I agree to conrply with all City and County ordinanccs and Statc l-aws rclating to construction, and hcrcby authorize rcprcscntatives of this City and County to enter upon thc above tnentioned properry for Applicant or Agent Pcrnritee nonlc D"t", l/_.zl{,0 Site-Work Underground Pole Bases Lisht Standards Spas, Pool, Fountains Siqns (monument) Life Safety /Low Voltaqe Fire Alarm / Dampers Communications Cable Building Under SIab / Floor lt I - Bonding / Grounding / UFER t4ilN MYat/ta,rt( Transformers I Torqueing Sub-Panels Air Conditioners Roof Top Equipment Factorv Wired Unit Walls (Conduit) Walls (Roush) Ceilinss (Hard & Soffit Rouqh Ceilings (T-Bar Roush) lVetef Release /l a tlVdL(tr t,ililw tr1v./4 d4fl Rouqh I Service N/eter I F!NAL lzl iltn M'ltttlM nff Notes, Remarks, Etc I Rev. 08-07-201 5 o o*", f 0.2 t .zozrl t