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ELECTRICAL.INSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNI'R BUILDI'R DI'I,CARATION I hereby affrnr under penalty of perjury that I arn exempt from the Contractors' License l-aw for the following reason (Scc.7031.5 llusincss and Protbssion Codc): Any City or County which requircs a pcrmit to construct, altcr, improvc, dcmolish or rcpair any structurc, prior to its issuance. also rcquires tlle applicant for such penuit to filc a sigrrcd slaternent that lp or she is licerrsed pursuant to thc pmvisions of thc Contraclor's l,icenscd law (Chapter 9. Commencing with Scction 7000 of Division 3 of the Busincss and Professions Code) or that lrc or she is exempt therefrom and tlre basis for tlre alleged exenrption. Any violation of Section 7031.5 by any appticant for a pennit subjects the applicant to o civilpenaltyof not rnorc than five hundred dollars ($500). _1. as owncr ol'the propcrty. or my clnployecs with wagcs as thcir solc compcnsation, willdo thc wnrk and the stnrcturc is not intcrxled or offeretl for sale (Sec.7M4, Busincss and Professions Cotle: Thc Contractor's Liccnsc [-aw does not aPPly to an owncr of the pmperty wlro builds or inrproves thereon, and wlxr does srch work himself or lrerself or ttuough his or her own employees, provided that such improvcmcnts arc not intended or offcrcd for sale. Il. howcver, trc building or funprovcnrcnt is sold within one )aar of completion, tlre Owncr Buil&r will have thc burden of proving thd hc or she tlid mt buill or inpmve tlrc propaty for thc purposc of llale). _1. as owner of the propcrly, am exclusively contracting with liccnscd conlractoni to conslrucl thc projcct (Sec. 7(Xa, Business and hrolbssi.m Code: The Contractor's License Law does not apply to an owner of proSrcrty who builds or improves thereon. and who contracts for such pro_iects with a Contractor(s) liccnscd pursuant to thc Conuactor's Liccnse Law). B. & P.C. I hercby affirnr unclcr pcnalty of pcrjury onc of tlte tbllowing _l have and will nuintah a Certil-rcate of Consent to Self-lnsure for workers' contpensation, as pnrvided for by Scction 3700 of the labor Code, for the ;rcrforrnance of thc work for which thc Srcrrnit is issucd. _l lrave arrd will nuintain workers' conrpensation insurarrce. as required by Section 3700 of the Labor Code, for the perfonrunce of the work for which this pcrmit is issucd. My workers' compcnsation insurance carricr and gxrlicy number are: Policy Number: Expires: _l ccrrify that in tlrc lxrfornrancc of thc work for which this pcrmit is issucd, I shall not cmploy any person in any m:rnner so as to becorne subjcct to thc workers' compensation laws of California. and agree that if I slnuld bccorrc subject to the workers' conpensation provisions of Section 3700 of the Labor C'ode, I slrall, forthwith conrply with those provisions.. WARNING: Failure to secure workers' compensation coverugc is unlawful, and shall subjcct an employcr to criminal penahics and civil fines up to one hundred tlnrusand dollars ($100.000). in addition to tlrc cost of comSrctsalion. danrages as provided for the .Section 3076 Codc, intercst and lecs. 0 4 DI'CI,ARATTON I hereby affirm under pnalty of pcrjury that I anr licenscd untler provision of Chapter 9 (conurrcncing with Sccrion 7000) of Division 3 of the Business and Professions Codc. arxl my licensc is in full forcc and effect. Licensc Class: Licensc Number: CONSTRUCTION LENDING AGENCY I hcrcby aflirm undcr pcnalty of pcrjury that thcrc is a construction lending agency for the pcrformance of thc work ltrr which this permit is issued (Sec. 3097. Civ. C.). Lender's Nanre: APPLICANT DECLARATTON I ffiy affrmunder penalty of pcrjury one of the following declarations: Denrclition Pcrmits-Asbcstos Notification Fedcral Rcgulations (Title 40. Part6) _Rcquircd l-etter of Notification _l certily thal the fcdcral regulations regarding &sbestos removal arc nol applicable to this project. _l certify that I luve rcad this application and state tlut thc above infornration is correct. I agrec to conrply with all City and County ordinances and State Laws rclating to building constructiorl and hereby authorize representatives of this City and County to entc{ upon the above rnentioned property for Alllllicant or r\gent Pcrnritcc nanlc purposes.r dl>n\zo Date:- Site-Work Underqround Pole Bases Lisht Standards Spas, Poo!, Fountains Siqns (monument) Life Safety /Low Voltaqe Fire Alarm / Dampers Communications Cable Building Under SIab / Floor I I 1l Bonding I Groundinq / UFER /a2v/b OZ"r'H ,ff Transformers / Torqueinq Sub-Panels Air Conditioners Roof Top Equipment Factorv Wired Unit Walls (Conduit) Walls (Roush) Ceilinqs (Hard & Soffit Rouoh Ceilinqs (T-Bar Rouqh)I / N/eter Release ttlzta 0lktM,K Rough Service Meter I .t I ,l/ FINAL '//rtl'-v Vf-/rvr7v - v ce Notes, Remarks, Etc. Rev. 08-07-201 5