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ELECTRICAL.I NSPECTOR RECORD APPROVALS DATE ID/SIG,COMMENTS OWNER BUILDER DEI,CARATION I hccby affm undo pcnalty of perjury that I m exmpt ftom thc Contmcton' Licw law for thc following llen (Sc.7031.5 Busine md Profsion Codc): Any City or County which requirc a pcmh to corotoct, Eltq, imprcvq &molish or rcpair my structue, prior to its isuancq also rcquirG thc applicst for such pcrmit to filc a signcd stat@@t that he or shc is liccNcd pmumt to th€ provisioN of the Contnctor's Liccnscd [:w (Chapt6 9. Commcing with Setiotr 7000 of Division 3 of thc B6in69 ed PrcfsionsCodc)orthathcorshciscxflptth6c&omedthcbasisforthcallcgcdamplion. AnyviolatiotrofSetionT03l.5bymy applicant for a permit subj€ts thc applicat to a civil pcnally of not morc thm fivc hundrcd dollds ($500). _1, 6s owner of the property, or my employees with wages as their sole compensation, will do the work and the structure is not intended or offered for salc (Sec.7M4, Business and hofessions Code: The Contractor's License Law does not apply to an owner of the property who builds or improves th6eon. and who docs such work himself or herself or through his or her own employees. provided that such improvanents are not intendcd or offerod for sale. If. howerrer. thc building or improvement is sold wilhin one )tar of complaioru the Orvner Builder will have the burden of proving ttum he or she did not build or improve the propoty for ttrc purpose of sale). \lllr, .ls owner of the property, am exclusively contracting with licensed contractors to construct the proiect (Sec. 7044, Busincss and hofession Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a Contracto(s) liccnsed pursuant to thc Contractor's License taw). -l am exempt under Section-, B. & P.C. DECI,ARATION I hereby affrm under pcnalty of perjury one of the following declarations: _l have and will maintain a Certificate of Consent to Sclf-Insurc for workcrs' compcosation, as provided for by Section 3700 of the Labor Code for the pcrformance of the work for which the pcrnrit b issued. _l have and will maintain workers' compcnsation insurance. as required by Section 3700 of the Labor Code, for the pcrformance of the work for which this permit is issued. My workcrs' compensation insurance carrier and policy number are: Carrier: Policy Number: Expires: U(rcertiS/ that in thc pcrformance of the work for which this pcrrnit is issued, I shall not employ any person in any manner so ,ls to become subject to the workers'compensation laws of California, and agree that if I should become subjcct to the workers' compensation provisions of Section 3700 of the l-abor Codq I shall. forthwith comply with those provisions.. WARNING: Failure to secure workers' compensation coverage is unlawful. and shall subject an onployer to criminal penalties and civil fines up to one hundred thousand dollars ($100.000). in addition to the cost of compensation, damages as provided for the Section 3076 of the Labor Code, interest and attorney's fees. t DECI.ARATION I hereby affrm under penalty of perjury that I am licensed under p,rovision of Chapter 9 (commancing with Section 7000) of Divirion 3 of the Business and Profcssions Code, and my liceirse is in full force and effect. License Dete: CONSTRUCTION LENDING AGENCY t hwby alfm unda pcnalty of pqjury thst th@ is a coNtruction hrding agocy for thc pafolmce of thc work for which this pqmh i3 issucd (Se. 3097, Civ. C.). [rnd6's Nmc: Lender's Address: APPLICANT DECLARATTON I herebyaffirmunder penalty of perjury one of the following declarations: Dernolition Permils-Asbcstos Notification Federal Regulations (Title 40, Part6) -Required lrtter of Notification _l certi& that the federal regulations regarding asbestos removal are not applicable to this project. W certiS/ that I have read this application and statc that the abovc information is correct. I with all City and County and County to entcr upon theordinanccs and State laws rclating to building construction, and hereby abovc mextioned property for inspection Applicnnt or Agent authorize "*",2llz_l?pzo Site-Work Underqround Pole Bases Light Standards Spas, Pool, Fountains Signs (monument) Life Safety /Low Voltase Fire AIarm I Dampers Communications Cable Building Under SIab / Floor Bonding I Grounding / UFER Transformers Torqueing Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Roush) Ceilings (Hard & Soffit Rough Ceilinqs (T-Bar Rouqh) Meter Release Rouqh Y -L/ _ZO Lert //49 *27 Service N/eter FINAL /z-6-a 2 Ztst /e,Z6rt *AV Notes, Remarks, Etc. Rev. 0B-O7-2015 License Number: Contractor:_ Permilee name (print):