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ELECTRICAL.INSPECTOR BECORD I <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcreby aftirm under penalty ofpcrjury lhat I am cxempt lrom lhe Contractors' Liccnsc Law lbr thc following reason (Sec.7031.5 <br />Busincss and Profession Codc): Any Cily or County which rcquircs a pcrnrit to conslruct. allcr. inrprovc. dcnxrlish or rcpair any <br />slruclurc, prbr to ils issuancc. also rcquires the applicant tbr such pcrmit to tlle a signed statcnrcnt lhal he or she is liccnsed pursuant <br />lo thc provisions of the Contraclor's Liccnscd Law (Chapter 9. Commencing with Scction 7000 of Division 3 of lhc Busincss and <br />ProfcssionsCodc)orthathcorshciscxcnrpllhcrcfromandthcbasislbrthcrllcgcdcxcnllion. AnyviolatiorrofScctionT0-ll.5byany <br />applicantlbrapennitsubjectsthe applicanttoacivilpenaltyofnotmorethanfivehundreddollars($5U)). <br />-1. <br />as owner of lhe property, or my cmployees with wages as thci sole conrpensalion. willdo lhe work and the structure is not <br />intcndcd orolfcrcdforsalc(Scc.T044,BushtcssardProfcssionsCodc:ThcContractor'sLiccnscLawdocsnotapplybililownerof <br />thc prcperty who builds or inlproves ther@il, and who does such work hinlselfor herselfor thrcugh his or hcr own enrpbyccs. <br />provided thal such improverenls tre nol intended orotlbred tbr salc. lt. however, the huildiug or inprovcnEnt is sokl withitr (nrc ,rtr <br />ofconrplction, lhc OwDcr Buildcr will hnvc thc burden of provirlg that hc or shc did not build or inrprovc thc propcrly for thc purfx)rc of <br />salc). <br />_1. rs owncr of lhc propcny. am cxclusively contracling with licenscd conlraclols lo corlslrlct thc projcct (Sec. 7(N4. Business <br />and PmfessionCodc:ThcConlraclor'sLiccnscLawdocsnotapplytoanowncrofpropcrtywhohuildsorinrprovcsthcrcon. <br />and who conlracts for such pmjccls with a Corilracbr(s) liccnscd pursuatrt lo lhc Contrtrctor's Liccnsc Law). <br />-Ialnexemplundcrscclk)n-.B'&P'C.[orthisreason' <br />WORKERS' COTIPBNSATION <br />DECLARA'TTON <br />I hcrcby afllrm undcr pcnnlty oI pe{ury onc of lhe ti)lkrwing dcclarutions: <br />-l <br />have and will rmintain a Certilicate of Consent to Self lnsurc for workers' compensatiul. rs provided fi)r by Section 37U) of the <br />Labor Codc. for thc perfonnance ofthc work tbr which thc pcrmit is issucd. <br />l/llhrvcandwilltuittninworkcrs cornpeisati(rlinsurancc.as tcquircdbyScclion3T(X)oftheLoborCode.lbrthcpcrli)rnmnceof <br />' thc work t'or which this pcrnlit ic issucd. l\4y workcrs' compcnstrtioD insurarcc crrricr and policy nunrbcr ilrc: <br />Policy oooDDlZt o <br />-l <br />certify that i[ lhc pcrfornrance of the work for which this permil is issued. I shall not eilrphy any pcrson in a[y nrunncr <br />so rs lo hcconrc suhjcct lo thc workcrs'compcnsatbn lnws ofcalilornir, nnd agrcc thal if I should hccotrrc suhicct b thc <br />workcrs'conrpcnsationprovisionsofScclion3T00ofthcLaborCodc.lshall.lo[hwilhconrl)lywilhlhoscprl)visidls.. <br />WARNING: Failurc to sccurc workers'conlpcnsrti()rl covcragc is uilhwful. und shall suhjcct an eillpbycr k) crimhral pcnaltics and <br />civil fincs up lo onc hundrcd thousand ilrllars (Sl(X).(Xx)). iil addithn to lhc cosl ofconrpcnsation,ris l)rovidcd for lhe <br />Scction of thc Codc. inlercst and atk)rncy's fccs. <br />I hereby alllm undcr peilalty of pc{ury that I am licensed under provision ofChaplcr 9 (connncncing with Section 7000) of Division 3 <br />of lhe Busincss and Professbns Code. and my license is iu tull lbrce md elltct. <br />Liccnsc C a Nlrilrll r:f 3 rzc z <br />4 Lr/ <br />CONSTRUCl'ION LENDING AGENCY <br />I hcreby afllrfi undcr Fnalty ofperjury thal therc is a constructbn leding agcncy lbr thc perfornrancc ofthc wt)rk lor which lhis pcmit is <br />issucd (Sec.3097. Civ. C.). <br />Lcndcr's Nunrc: <br />Lcndcr's Addrcss: <br />APPLICANT DECLARATION <br />I hmby atiinn undcr pcDalty of perjury one of the following dcclarations: <br />Dcmolition Permits-Asbeslos Noli6catioD Fcdcral Rcgulations (Title 40. Part6) <br />f,fi t\eqdr ed l*r tcr o f Noti lication <br />///Ll cenily thtt lhe federnl regulations rcgarding asbcstos rcmoval rrc not aplllicahlc k)lhis pmjccl. <br />I agrcc to conrply with all City and Countya0d stalc th{l lhc rtx)vc inli)rnrdti(nl is corrcct. <br />corrslrlrclion. and hcreby ruthorizc lhis ( ily xn(l (i)ntrly l(, cillcr u|]on lhc <br />ahovc nrntiotrcd frofrcrly lbr <br />Applicont or Agcnt <br />I'ermitee nanre (/ <br />,^r., z/-?/i <br />Site-Work <br />Underqround <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Sions (monument) <br />Life Safetv /Low Voltaqe <br />Fire Alarm / Dampers <br />Communications Cable <br />Buildinq <br />Under Slab / Floor <br />Bondinq / Groundinq / UFER <br />Transformers <br />Torqueing <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouoh) <br />Ceilinqs (Hard & Soffit Rouqh <br />Ceilinqs (T-Bar Rouqh) <br />Meter Release <br />Rough <br />Service lt/eter il <br />FINAL aW&W <br />N -4 <br />tf ^,. n, n7