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ELECTRICAL-INSPECTOR RECORD APPROVALS DATE ID/SIG. COMMENTS 0WNEI! II UI L DER DllLCARATI0N I hereby a rtin n under penalt y of pc1ju1)' that I am cxempl from the Co ntractors· Licc-nse La w for the fo ll owing rc.ison (Sec.7031.S. · Site-Work 13usiness and Pro fession Code): Any City CH' County which requires a permit to co nstmct. alter. im prove. demolish or rlvair any structure, prior to its issuance. a lso requ ires the applicant for s uch permit to fi le a sig ned stmement lhal he or s he is licensed 'pursuant Unde rqround to the provis io ns o f the Contractor's Licensed Law (Chapter 9. Commencin g with Seciion 7000 of Divis ion 3 o f th e Business and Po le Bases Pro fessio ns Cod e) o r that he or s he is ex.empt the refrom and the basis fo r the alleged exem pt ion. Any v io l.i t ion of Section 7031 j by any ap pl icanl for a penni1 subjects th e appl icanl to a ci vil penalt y of not more limn five hundred dollars ($500). Liqht Standards ~'• as owner of th e pro perty. or my em ployees wilh wages as their sole compensat ion. will do lhe work and the s1n1cture is not Soas, Poo l, Fountains intended or o ffe red for sale (S t-c. 7044. Busin ess an d Pro fe ssions Code: The Contrnc tor·s License Law docs ncH apply to an owner of th e property who buil ds or im proves thereo n. and who docs sucl1 work himself or hersel f or throui;h hi s or he r own empl oyees. Siqns (monument) provided tlm t such improvements arc not intended or oITered fo r sale. If, however. the bu ild ing or improvement is so ld with in one year of comp letion, the Owner Build er wi ll ha ve the burden of proving th at he or she did not build or improve the propc11y fo r the puri:ose of sale). Life Safetv /Low Voltage _I. as owner oft he pro pcity. am exclusive ly contract ing wi th licensed con trnctors to cons t111c1 lhe project (Sec. 7044. Business Fire Alarm / Dampers and Prufc.ssion Code: The Co ntractor's License Law does not apply to an owner o f property who bui lds or improves I hereon. and who coutrm.:ts for surh projcc1s with a Cont ractor(s) \k cnsed pursuant to the Conl ractor·s Li cense Law). Communications Cable _1 mn exempt und er Sec tion . B. & P.C. for t his reason. Dale: O w ner : \V0RKEIIS' COMPENSATION Buildina DE!;L A R~T ION Under Slab I Floor I hereby affinn under pennl ty of pcrjLU)' one of t he fo llow ing declarat ions: Bond ina / Ground in q / UFER _I have and will mainta in n Certificate ofC'onscnt to Sclf•lnsurc for workers· compcnsn1io11. as prodded fm· b)' Section .'700 o f th e Labor Code. for t he perfonnance o f lhe work for which the permit is issued. Transformers _I have and w ill ma inta' orkc rs' compensat ion insurance. as rc'(J ui red b~i~/700 of t he Labor C'o de. for tyonmnce of T orqueinq th e work !£r wrch this p ' ,it is issued. My workers' ~•~ion ins~ance ca, r 'Y'd pohcy m~are: Sub-Panels Cmi-;;',. I -c;~ ·o 1"''11,--•--¥11\ . tl\-::0 tAI\., CN1C -'Sij I Air Co nd itioners Policy Nu mb er: Expire s: Roof T op Equ ipment _I certify th at in the performance of the work for whi ch this permi t is issued. I shall not employ any person in any mmmer Factorv W ired Unit so as to lx.--come s ubject to the workers' com pensation laws of Ca lifornia. and ag.ree that if I sho uld become suhjecr to the workc.,·s' co mpensat ion provisi ons of Sect inn 3700 of the Labor Code, I shall, fmthw ith comply with t hose: pmvisions. Wa lls (Conduit) WARNING: Failure to secure workers' co mp:E~' coverage is u la w fu l. and shall subject an employer to c,imioal pc,1altics and Walls (Rouq h) civil fines up to one hundred thousand do llar $100,000). in add~st o f co mpensa tion. damage, a, provided fo r the Cei linas (Hard & Soffit Rouq h Sectio n 3076 of the Labor ~~de, in ter1;5t and alt m ey·s fees. (&-: Ce ilinas ff-Bar Rouqh) Date : "9-( S -/G Applicant: , ~ 1 . LI CENSEll C O NTRACTOR Mete r Release llECLARATI ON I hereby a ffirm under penalt y of perjury 1h:1t I am licensed und er pm vision of C\1ap1 er 9 (commencing with Sect io n 7000 ) of Division 3 "' "" '"'"~ .. , ... , .. '""""' ., "4_"" ·=· . Rouqh u .... ,-R Uceo ""'.~ Got./~ ff-Service Meter {J \ ~3--16 t ',1 .,f · FINAL l~-Z.9-17 .Jd~Jc>J f/V0 Dale: .,... 7 C ont · ..... , ----,;. Notes , Remarks, Etc. CONSTRUC TION L EN DI NG AGENCY I hereby affi rm un der penalty o f pc1ju1)' I hat thc..,.c is a construction lending agency fo r the pcrfonnancc of the work fo r which this pc11nit is issue d (Sec. 3097. C iv. C .). Lcndcr·s Name: Lend er 's Addrt'Ss: A P PLICANT lllcO ,AR ATI0N I hereby affi1111 und er penally of pc1jury one of th e foll owi11g dcclnrat ions: Demo liti on Pcrmits•Asbestos Notification Federn l Regul at ions (Tit le 40. Part6) _Required Letter of Notification _I certi fy that the federal rc:1•11 · · ing. [1Sbcstos removal nre not npplic abl c to th is project. ~' '""' '"' ' ~',:i: '"" """'"~"' '"" '"" '"'""""'" '•-' •-• S'"""°'"" u,, •• '"""' ordin ances and Stal e L s rclat mg to bu1ld111g const ctmn. cµj ·c by autho rize reprcsc11tal l\'t'S of 1l11s Oty and County to enter upon tl1e above mentioned prop rty fo r inspcc1ion purpos .· ·•---/~.... / 6 "'17-r--, A pplicant or Agent Sig ,. · ''t',✓= Date: { ' --',Q1; r crmitcc namc (p rint): '(·(', c:::-....e~ -"'t .. --r,--,-,.