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ELECTRICAL-INSPECTOR RECORD t APPROVALS DATE ID/SIG.COMMENTS OWNI'R BIJII,DIiR DEI,CARATION I hereby affrnr under penalty of pcrjury that I anr exenrpt frcm the Contractors'License [-aw for the following reason (Scc.7031.5 lJusincss and Prolbssion Codc): Any City or County which rcquires a pcrrnit to construct, altcr, itnprovc, dcmolish or rcpair any structure, prior to its issuance. also requires the applicurt lor such perntt to fih a sigrrcd slatement that lre or she is licensed pursuanl to tl-*^ provisions of the Contrlctor's Licenscd t-aw (Chapter 9. Commcncing with Section 7000 of Division 3 of the Business and Professions Code) or that lrc or she is exempt therefronr and tlrc basis ftrr tlrc alleged exenption. Any violation of Section 7031.5 by any applicant for a perrnit subjects thc applicant to a civil pcnalty o[ not more than five hundred dollars ($5tlO1. _1. as owner ol'thc propcrty. or my crnployccs with wages as thcir solc compcnsation, will do the work and thc structurc is not interxletl or offcretl for salc (Scc.7014, Busine.ss and Pnrfession^s Code: The Contractor's Licensc l-aw does not apply to an owner of the property wlm builds or improves tlrre<rn, and wllo does such work himself or lrerself or througlt his or her own entployees, provided that such irnproverrcnts arc rnt intcndcd or offercd for salc. If. trowcver, the building or improvcnrnt is snld within onc )tar of conrpletiotr, tlrc Owrrer Builder will havc the burden of provirrg ttrat lr or she did not buikl or inprove Or propaty for thc purposc of vdh). _1. as owner of the propeny, am exclusively contracting with licensed contractors to construct thc prujcct (Sec. 7044. Business arxJ hofessi<rn Code: The Contractor's License Law does not apply to an owner of proprcrty who builds or intproves thereon, and who conracts for such projects with a Contractor(s) liccnscd pursuant to thc Contractor's Liccnse l-aw). -l anr exempt under Sectiott-, B. & P.C. for tltis reason. f 1... ^. WORKEIIS' COMPENSATTON DECLARATION I hereby affirm under penalty of perjury one of the tbllowing declarations: _I have and will ntaintah a Ce(ilicate of Consent to Self-lnsure for workers'c'om5rnsation, as provided for by Section 3700 of the Labor Code, for the pcrformance of the work for which the perrnit is issucd. -l have and will maintain workers'c<lnrpcnsation insurarrce, as required by Section 3700 of the [:bor Code, for lhc perfornunce of the work for which this pernrit is issucd. My workcrs' compensation insurance carrier ard policy number are: Policy Number: Expircs: _l ccrlity that in thc lrcrfrlrnunce of tlrc work for which this pcrmit is issucd, I shall not cnploy any pcrson in any manncr so as to bccome .subjcct to the workcrs' cornpensation laws of California. and agrec that if I should becolne subjcct to the workers' cornpensation pruvisions of Section 370O of the Labor Code, I slnll, forthwith conrply with those provisions.. WARNING: Failure to secure workers'compensation covemge is unlawful, and shall sub.iect an employer to criminal penaltics and civil fines up to orrc hundred th<lusand dollars ($100.000). in addilion to lhe cost of compensation, damages as provided for the Scction 3076 of the l,abor Code, interest and attorrrcy's [ees. Date: Applicant: LICENSED CONTRACTOR DECLARATION I hereby affrm under penalty of perjury that I arrr licensed under provision of Chapter 9 (conrnrncing with Section 7000) of Division 3 of the Business and Pmfessions Code. and my license is in full forcc and cffect. License Class: Licensc Number: Datc: CONSTRUCTION LENDING AGENCY I hcrcby allirm undcr pcnalty of pcrjury that thcre is a construction hnding agency for the pcrlbrmance of the work lbr which this permit is issuerl (Sec. 3097. Cir'. C.). [*nder's Nanre: APPI,ICANT DECLARATION I hcn$y aflirnr under pnalty of perjury onc of thc lbllowing dcclarations: Dcnnlition Pcrmits-Asht'stos Notification Fcdcral Rcgulations (Titlc 40, Part6) _Required lrttcr of Notifrcation _l certify that thc l'cdcral rcgutations rcgarding a.sbcstos rcnroval arc not applicablc to this projcct. _l ccrrify tlrat I have read this application and statc that the abovc informalion is corrcct. I agrcr: to comply with all City and C<lunty ordinanccs and State laws rclating lo building construction, and hereby auttnrize rcprcscntatives of this Cily and County to cnter upon thc above rrrcntioned propcrty for inspection purposes. Allplicant or Agent Dale: Pcrmitec nomc (print): Site-Work Underqround Pole Bases Light Standards Spas, Pool, Fountains Signs (monument) Life Safety /Low Voltage Fire Alarm / Dampers Communications Cable Buildinq Under Slab / Floor 1l I ^a Bondinq I Groundi no I UFER I a / I u 7/DYTVV t Transformers I Torqueino Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Roush) Ceilinqs (Hard & Soffit Rouqh Ceilinqs (T-Bar Rouqh)Ir t ?d [/eter Release ilJ I I Rough I I Service lt/eter IL L 7/0 nk#81 2/t FINAL l1/A -L( ,lznu.%f/ Notes, Femarks, Etc.\ -l Ao C2rl Flev. 08-07-201 5 t1) Vl ,tt)