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ELECTRICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG COMMENTS OWNI'R IIU II,I)IiR I)T'I,CARATION <br />I lrcreby afl-rnr under penalty <lf prjury that I arn exenlpl frorrr the Contraclors' License l-aw f<rr the following reason (Sec'.7031.5 <br />Busincss and Prol'cssion Codc): Any City or County which rcquircs a Jrcrrnit to construct, alter. irnprovc. derrxrlish or rcpair any <br />slructure, prior to its issuance. also requires the applicant ftrr such pemilt to fih a signed slatemenl lhat lre or she Ls licerrsed pursuarrl <br />to the provisions of tlr Contractor's l,iccnscd law (Chaptcr 9. Comrncncing with Scction 7000 ol'Division 3 of thc Busincss and <br />Professions Code) or that lrc or slre is exerqrt tlrcrefronr ard tlre trasis lbr tlre alleged exenlplion. Any violatiou of Seclion T03 l .5 by any <br />upplictnt for o penrrit suhjects the applicant to a civil penalty of not rnore than five hundred dollars ($5m). <br />_1. a-s owner ol'thc prot!*rty. or rny ernployccs with wages as thcir sole compcnsation. will do thc work and thc stnrcture is not <br />interxlctl or offered for sale (Sec.7M4. Business and Professiorrs Cotle: The Contraclor's License Law does not apply to an owner of <br />the property wlxr builds ur inrproves thereon, and wlxr does such work himself or lrerself or thr<lugh his or her own enrployees, <br />providc'd that such imprrvcmcnts arc rx)t intcnded or ollercd for sale. Il. however. the building or inprovcment is sold within one ycar <br />of completion, llre Owner Builder will hare the bunlen of pruving that he or she dirl not build or improve tlre propeny for thc purpose of <br />salc). <br />_1. us owner of the property. anr exclusively contracting with licensed conlractors to construct the projcct (Sec. 7(X4. Business <br />and hulbssiorr Code: The Contractor's License Law does not apply to arr owner of property who builds or inrproves thereott. <br />and who contracts f<rr such proit'cts with a C()ntract()r(s) liccnscd pursuant lo tr*\^ Grntractor's Liccnsc Law). <br />_l am exempt under Section_, B. & P.C. lbr this rea.son. <br />Date: Owner: <br />WORKERS' COMPENSATION <br />DECLARATION <br />I hereby aflirm under grcnalty of pcrjury one of the following declarations: <br />_l have ard will rrraintah a Certificate of Consent to Self-lnsure for workers' con4rcnsation, as provided for by Scction 3700 of the <br />labor Code, for the performance of the work lor which the permit is issued. <br />_l have and will nraintain workers' conrpensation insurarrce, as required by Seclion 3700 of thc hbor Code, for lhe performarrce of <br />thc work for which this permit is issucd. My workers' compcnsation insurance carrier ard gnlicy number are: <br />carrier: af trTE C.OF{\ e <br />poricy *r,uo.r' q 1-1 LtLt \ O - ?-<r Expires:Lr-q -Ll <br />_l ccrtity that in tlrc prfornrancc of thc work frrr which this pcrnrit is issucd, I shall not cn4rloy any pcrson in any manncr <br />so as to bccornc sulrjcct to thc workcrs'cornlrcrrsaliorr laws of California. and agrce that if I should bccotnc subjcct to thc <br />workers' cornlrcnsation provisions of Section 3700 of the Lalror Code, I slurll, forthwith conrply with thosc provisiorts.. <br />WARNING: Failure lo secure workers' cornpensation covemge <br />civil lirres up to orrc lrurrdred lhou.sand dollars (S100.0001. irt <br />is unlawful. and rn ernploycr to criminal lrcnahies iurtl <br />danuges as provided frlr lhe <br />Scction 3076 of thc Latror (ixlc, intc'rcst and attorncy's <br />pr,". t(-tQ -ZO <br />I hereby affinu under pnalty of perjury that I anr licensed under provision of Chapter 9 (corrmrencing with Sectiron <br />of the Bu.siness and l'rofessions Code. and mv license is in full forcc and el'fect. <br />of Division 3 <br />Liccnse <br />4{, <br />,",u \(-tq.z.) <br />CONSTRUCTION LENDING AGENCY <br />I hcrcby al'lirrn undcr p^-nalty of pcrjury that thcrc is a construction lcnding agcncy for thc performancc ol'thc work ltrr which this permit is <br />issued (Sec. 3097. Civ. C.). <br />Lender's Naute: <br />lrnder's Adttress: <br />APPI,ICANT DECI,ARATION <br />I lrrcby aftirnr undcr Jrcnalty of pcrjury onc of thc following declarations: <br />Dcnxrlition Pcrnfts-Ashcstos Notification Fcdcral Rcgulations (Titlc 40, Part6) <br />_Rcquircd lrttcrr of Ntlification <br />_l ccrtily that thc fedcral rcgulations rcgarding asbcstos rcmnl'al arc nol applicable to this project. <br />_l ccrtily tlral I havc rcad this applicaliou iuxl statc tlral lhc ahrvc inlirrnralion is corcct. I agrcc to conrply witlr all City and County <br />ordinanccs and Statc [:ws <br />above rrcnt ioned pn)peny <br />authorizc reprc'scntativcs of this City and County to cnter uJnn thc <br />Allplicarrt or Agent <br />Pcrnritec nanlc <br />[rrr <br />truilding <br />[- t<-Lg <br />Site-Work <br />Underqround <br />Pole Bases <br />Lioht Standards <br />Spas, Pool, Fountains <br />Signs (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Buildinq <br />Under Slab / Flnnr <br />Bondins hdroundinljr I UFER /2--l{'Ztb ,k-&LrTransforM <br />Torqueing <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilinqs (Hard & Soffit Rouqh <br />Ceilinqs (T-Bar Rouoh) <br />Meter Release t24*?b Ol ?D b At)t <br />Rough <br />Service N/eter <br />FINAL /Z-lqt -D lLc lst Jentr<> -2n <br />Notes, Remarks, Etc. <br />Bev. 08-07-201 5