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ELECTRICAL-INSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNI,R BUII,DI'R DEI,CARATION I hcreby affirnr under penahy of perjury that I arn exempt frum the Clontractors' License [:w for the following rcason (Sec.7031.5 Busincss and Prol'ession Codc): Any City or County which requires a pcrrnit to construct, alter, itnprove. demolish or repair any structure, prior to its issuance. also requires the applicant for such pernrit t<l fih a signed statemenl that he or she is licerrsed pursuanl to thc provisions of thc. Contractor's l.iccnsed t-aw (Chapter 9, Commcncing with Section 7000 of Division 3 of the Busincss and Professions Cotle) or that he or she is exempt therefronr and tlre basis for tlre alleged exenrption. Any violation of Section 7031.5 by any applicant for a pennit subjects the applicant to il civil pcnnlty of not more than five hundred dollars ($500). _1. as owncr ol'lhe proprty. or my crnployces with wagcs as their solc comgrcnsation, wil! do thc work and the structure is not irrterxletl or offered ftrr salc (Ser'.7(}14. Business and Prufessions Code: The Contractor's License Law does not apply to an owner o[ the property wllo builds or inproves tlrreorl arxl wlxr does such work himself or lrerself or through his or lrcr own entployees, providcd that such irnproverlrcnts arc not intcndcd or oll'cred for sah. ll. howcvcr. thc building or inprovennnt is sold within onc )aar of conrphtkrn, the Owrrcr Builtler will have the bunlen of proving that lrc or slrc did not build or improve thc propaty for thc purposc of sale). _1. as owner o[the propcrty, am exclusively contracting with licenrcd conlractoni to construcl thc project (Sec. 7044, Busincss and hufession Code: The Contractor's Licerrse Law does not apply to an owner of property who builds or improves thereon. and who contracts for such projccts with a Ctrntractor(s) liccnscd pursuant to the Contractor's Liccnse kw). -IantexemptunderSectiott-,B'&P.C'lbrtltisreason.I l^r,.. WORKItrRS' COM PENSATION DECLARATION I hercby atlirm under penalty of pcrjury one of the tbllowing declarations: _l have ard will nnintain a Certificate of Consent to Self-lnsure for workers' conrpensation, as provided for by Section 3700 of thc [:bor Code, for the Jrerfornuncc of the work for which the prmit is issued. d nor. and wilt nuintain workers' compensation insurance, as required by Section 3700 of thc l-abor Code, for rhc perfornunce of lhc work for which this pcrmit is issucd. My workers' conrpensation insurance carrier and policy number are: ,*,*,,' Y$€FVQ-{L(iV (rta(A6<rovP.t ltvS poricyNrb",,'CIN(bfl1-SZ- d9 Expires:t o _l ccnify that in thc lrcrfornuncc of thc work for which this pcrmit is issue'd, I shall not cmploy any lrcrson in any manner so as to becornc subjcct to lhc workcrs' compcn.salion laws of California. and agree that if I should bccome subjcct to thc workers' corrqrcnsation provisions of Section 3700 of the Labor CorJe, I stull, forrhwilh conrply with thosc provisions.. WARNING: Failure to secure workers' colnpensation coverage is unlawful. and shall subject an employer lo criminal penaltias and civil fines up to one lrundred thousand dollars ($100.000). in addition to tlrc cost of comSremation, danrages as provided for lhe Scction 3076 of thc Lakrr intcrest and attorncy's [ccs. t L'\ Annlicant: D( LICENSED ffiTRACTOR DIiCLARATION I anr licens'etl untler prcvision of Chapter my license is in full forcc and effect. a I hercby affirnr under pnalty of perjury that , of the Business and Professions Code. anJ 9 (conurrcncing with Section 7000) of Division 3 ta License Nunrber: a CONSTRUCTION LENDING AGENCY I hcrcby aflirm undcr pcnalty of pcrjury that thcrc is a construction lending agcncy for thc pcrformancc of the work ltrr which this pcrrnit is issued (Sec. 3097, Civ. C.). Lender's Nanre: Lrnder's Address: APPI,ICANT DECLARATION I trrchy aflrnr undcr Jrcnalty of pcrjury one of thc following dcclarations: Dc nro l it io n Pcrnrits- Asht'stos Nr[ificat ion Fc'dcral Rcgu lat ion s (Tit le 40, PartO _Rcquircd lrttcr of Notification _l ccrtily that thc l'cdcral rcgulations regarding asbcstos rcrrnval are not applicablc to this projct. Xlh"nifythat I havc rcattthis applicatiorr amt statc tlrat thc ahrve infornulion r /or{nanccs and Statc Laws rclating to building construction, and hcreby authorizc is corrcct. I agree to comply with all City and County abovc rnentioned properly for inspection purposcs. Applicant or Pcrmitcc nAmc rcprcscntativcs of l,|,-ill ,-Wi=- Site-Work Underqround Pole Bases Liqht Standards Spas, Pool, Fountains Siqns (monument) Life Safety /Low Voltage Fire Alarm / Dampers Communications Cable Building Under Slab / Floor I tl- -2 Bondinq I Groundinq I UFER UIT 'la /IfD t Transformers I I rl Torqueing Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rouqh) Ceilinqs (Hard & Soffit Rouoh Ceilinqs (T-Bar Rouqh) Meter Release I bM '47 lr Rough 1 I t tl Service [/eter -l 7t -lc I lJ,6>U/tr1 FINAL Ir , 4,74'I )>k Notes, Remarks, Etc.I I ,/ Bev. 08-07-201 5 \ a