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ELECTRICAL.INSPECTOR RECORD APPROVALS DATE ID/SIG COMMENTS OWNI'R BUII,DER DEI,CARATION I hereby affirnr under penalty of perjury that I am excmpt from the Contractors' License law for the following reason (Sec.7031.5 Business and Profcssion Codc): Any City or County which requires a pcrmit to construct, alter, irnprovc. demolish or repair any structure, prior to it.s issuance. also requires the applicant for such ;rcrntt to file a signed staterrnt that lre or she is licenscd pursuant to the provisions of thc Contractor's Liccnscd l:w (Chapter 9. Commencing wilh Section 7fiX) of Division 3 of the Business and Professions Code) or that lre or slre is exempt tltrefronr and tlrc basis for tlre alleged exenption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($stttt). )cL\ as owncr ol'thc propcrty. or my ernployees with wages as their sole compensation, willdo thc work and the stnrture is rnt interxlcd or offcred for sale (Sec.7(X4, Business and Professions Code: The Contractor's Licensc Law docs nol apply to an owner of the pmperty wlro builds or inrproves thereon" and wln does such work himself or lrerself or through his or her own enrployees, providcd that such improvcrrnts are not intendcd or offcred for sah. ll, howcver, thc buiHing or inprovcnrcnt is sold within onc )€ar of completion, tlrc Owner Builder will have the burden of proving thu he or she did not build or improve the properry for thc purposc of yale). _1. as owner of the property, am exclu.sively contracting with licenscd contractors to construct the project (Sec. 7Ma. Businers arxl Prolbssitn Code: The Contractor's License Law does not apply to an owner <lf property who builds or inrproves thereon. and who contract.s for such projccts with a Contractor(s) liccnscd pursuant to thc Contraclor's Licensc l-aw). _l anr exempt under rcas()n. ,r^r", b il Z/N//?,t/,r I hereby aftirnr undcr penalty of pcrjury one of thc tbllowing declarations: I have and will nninlahr a Certiticate of Consent to Self-lnsure for workers' cornpensalion, as provided for by Scction 3700 of the I-abor Code, for the Jrerforrnarrce of the work for which the pcrmit is issued. _l have and will nuintain workers' conrlrcnsalion insurance, as required by Section 3700 of the l-abor Code, for the perfornunce of the work for which this Jrcrnrit is issued. My w<lrkcrs' compcnsation insurance carrier and policy number are: Policy Numbcr: Expires: &rccrrify lhat in thc prltrrnnnce of thc work for which this pcrmil is issucd, I shall not cmploy any lrcrson in any manncr so as to becomc subject to thc workers' compcrsation laws of California, and agree that if I should becomc subjcct to thc workers' conlp€nsation provisiors of Section 3700 of the Labor Codc, I shall, forthwith conrply with those provisions.. WARNING: Failure to secure workers' compensation coverdge is unlawful, and shall subject an ernployer to crirninal pcnaltbs and civil lines up to orrc hundred thousand dollars ($100.000). Scction 3076 of thc [abor Code, interest and attorney's lbes. in addition to the cost of danuges as provided for lhe o^r", . / Z/ et// Za ?a, I hereby affirnr untler penalty of perjury tlut I anr licensrerl 9 (corrrnrncing with Section 7000) of Diviin 3 of the Business and Professions Code. and my license is in full force and effect. License Class: Licerrse Number: CONSTRUCTION LENDING AGENCY I hcrcby aflirm undcr pcnalty of pcrjury that thcrc is a construction lcnding agency for thc pcrformance of thc work lbr which this pcrmit is issued (Sec. 3097, Civ. C.). knder's Name: lrnder's Address: A PPI,ICANT DECI,ARATION I Hry affrnr undcr Jrcnalty of pcrjury onc of thc folhwing dcclarations: Dcnrolition Pernrits-Asbcstos Notification Federal Regulations (Titlc 40, Part6) _Rcquircd Lcttcr of Notification this pro_icct. Orc above rncntioned propcrty ftrr inspection Applicant or IDcrmilec nanle mt",y'n t/ /' '' "? Site-Work Underqround Pole Bases Liqht Standards Spas, Pool, Fountains Sions (monument) Life Safetv /Low Voltaqe Fire Alarm / Dampers Communications Cable Buildinq Under SIab / Floor Bondinq / Groundinq I UFER Transformers Torqueing Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rouqh) Ceilinos (Hard & Soffit Rouqh Ceilinqs [-Bar Rouqh) N/eter Release Rouqh Service N/eter FINAL lz//l/?n?r A ,Y-/r,/ Notes, Remarks, Etc.I /- Yl/ Rev. 08-07-201 5 a Contractor: