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APPROVALS DATE ID/SIG COMMENTS OWNI]R AUII,DI]R DI.]I,CARA'IION J <br />IhcrcbyaffirnrunderpenaltyofpcrjurythalIilnexcnDtfromtheContractoN Lic.nscbwforthcfollowinSreaen(56.7"11.5 <br />llusincss and Prot'cssion Codc): Any Cily or Counly which rcquircs a pcrmit to construct, altfi. irnprovc. dcrmlish or rcps \ <br />structure, frior b ils issuance. also requires the apl)licxnl fi)r such pernril k) filc a signed slatctrEnt tha( lE or shc is licen*,t puN{ <br />to lhc pmvisions o[ thc Conkactor's l-iccnscd hw (Chaptcr 9. Commcncing with Scction 7(XXJ ol Division 3 of thc Busincss and <br />ProlessionsCode)ortlHtlEorsheiscxeilDltherefionrandtlEb{sislortheallegedexemption. AnyviolationofSectionT03l.5byany <br />npplicnnlforapermilsubjeclsrhc applicanttoacivilpenrltyofnotmorethanlivchundrcddollrrs($5u)). <br />_1. as owncr ol th!. propcny. or nry crnployccs with wages as their $lc compcnsation, willdo thc work aM the strcturc is not <br />intcrr.lerl oroffererlforMlc(Scc.7(H,l.BusirrcssandProfcssionsCodc:TheConlra(tor'sLiccnseLlwd@snotapplytoanownerof <br />lhe l)rcltdy wlm builds or iqnoves lherdnl and who does such woIk himselfor herselfor lhrough his or her owD en)ployecs, <br />prolidcd that such irnpovcmnts {c ftn in(c&lcd orollcrcd for slc. If. hotrcvcr thc buiHing or inprovclrcnt is $ld wifiin onc ycd <br />ofconpleri)\ llE Owncr Buildcr will havc the burdcn ofpNvirs lhd he or she did ftx blild or irpNve 0E prcpdty for lh. purF)s of <br />salc). <br />_1. as owner ofthe prl)pcny, um axclusively contracting with liccnsed contruclors to conslruct the prcject (Sec. 7()i14. Busincss <br />arxl hutiisionCodc:TheContract)r'sLicenseLawd(rsnotapplytoanownerofpropenywhobuiklsorimprovesthereon. <br />and who contracts lirr such p(,iccts with a Conlract)(s) liccnscd pursuul 10 lhc Contrachr's Liccnsc tiw). <br />-l <br />anr exempt under Section-. B. & P.C. fbr this roason. <br />UIIBIE&LCAMIJNIAII9N <br />DECLARATION <br />I hcrcby aftirm under pcnahy ofperjury one ofthe t'ollowing dccleations: <br />_l havc od will nuintah a Ccniticate of CoDsent to Sclf-lnsur. fot workcrs' conDcnsation, as pmvidcd for by Scction 3700 of the <br />trbor Cql.afor lhc fErfonlrffie of thc uo* tor which thc pornit is issucd. <br />,ffhaveandwillnraintrinworkc6'conrpctralioninsuratrcc,as rcquiredbyScclion3?00ofthckborCodc,forlhclrrfomtmcof <br />thc work lbr lhis is issued. <br />Sworkqs' <br />corpcBstion iDuruce cuis ard tDlicy number de: <br />Policy 3 <br />_l ccrlity that in thc lrcrlinmancc of thc wolk for which this pernlit is issucd, I shall not cnrploy any lrcrson in any manncr <br />No astobcconEsubjccllothcworkcrs'cotrrpcnsationlawsofcalilornia.andasrcclhatiflshouldbccorrcsubjecltolhe <br />workers conrlEn\rtionprovisionsofSectiotrlT00ofthcLahrrCode,lslull,fonhwithconlplywilhthosprovisioils.. <br />WARNING: Failurc lo scure workers' con{Fnsalion is unlawful. nnd subjcct in eilTloler lo crirniMl penalies and <br />cotrpensillion. datruges as provided ft)r lhecivil lliles up k) orrc hundred thousald dollars ( l additiur k) lhe <br />ScctioD 3076 ofthc lltx,r Cillc. intcrcsl <br />o,,., 3 l\\tzo <br />and <br />I hercby afftrm und.r penrlty of perjury that I nnr licen*rj undcr provision ofChaptc. 9 (conurcncinS wilh Scction 7000) of Division 3 <br />of the Business and Pre[essions Codc. and mv liccnse is in [ull force und effect. <br />v 2-I <br />Liccnse <br />CONSTRUCTION LENDING AGENCY <br />I hcrcby allirm undr.r p!nalty of pcrjury that thcrc is a construclion bnding a8crcy for thc lErformamc ol thc work for which lhis pcnnit is <br />issucd (Scc. 3097. Civ. C.). <br />Lendcr's Nanrc. <br />Lrnder's Addrcsr: <br />AE!.!SLAEC!,ARA'UAN <br />I hiEby affimunder pcnalty ofperjury onc of thc following dcclaations: <br />Denplitbn Pcrnits-Asbcstos No(ificati()n Fcdcral ReSulations (Tille 40, Pff6) <br />-Rcquircd <br />httcr of Ndfication <br />ldc(ilv rhat lhc <br />-Z*.^r'r,,^,u*" <br />ltdcral rcgulations rcgdding a\bestos rcmoval {c not applicablc to this pmjet. <br />rcil(lthis <br />ordinanccs md Statc Liws rclding 10 <br />abovc rcntioncd prcperlv for <br />Applicanl 0r Agent <br />l'crmitcc trdmc <br />Site-Work <br />Underground <br />Pole Bases <br />Liqht Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safety /Low Voltaqe <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor <br />Bondinq / Groundinq / UFER <br />Transformers <br />Torqueinq <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 Rouqh) <br />lVleter Release <br />Rough <br />Service l/leter ;l It <br />FINAL 5l tql'lt)YKY'il xkw <br />Remarks Etc. <br />ELECTRICAL.INSPECTOR RECORD <br />I <br />It u <br />"*", 7.t\\ ) z-O <br />\\