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ELECTRICAL.INSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hqcby aflirm unda pcnalty of pctjury that I dr cxcmpt ftom thc Contractots' Licffi [rw for thc following rcmn (Se.7031.5 . Buinw and Prof*ion Codc): Any City or County which rcquira a po'mit to coretruct. ahq. improvc. donolish or npat my structuc, Fbr to its issumcc. alm requirc thc applicat for such pcmh to filc a signcd statdmt that he or $c b licctrs€d pwwt' to the provisioc of thc Contrrctor's Licmsed taw (Chapt6 9. Comocing with Setion 7000 of Division 3 of thc Buine ud Prcfcsions Code) or that hc or sh€ is qmpt thqcfrom ud the basis for the allcgc{ qmption. Any violation of Serion 703 I .5 by uy appliciltforapcmitsubjelsthc applionttoacivilpcnaltyofnotmorcthmfivchundrcddollus($500). _1. as owner of the property, or my employees with wages as their sole comporsation, will do the work and the structure is not intended or offered for sale (Sec.7M4. Business and hofessions Code: The Contractor's License law does not apply to an owner of the properly who builds or improves thcron, and who does such work himself or hersclf or through his or her own employccs, provided that such improvonents are not intended or offered for sale. If, however. the building or improvement is sold wilhin one )rcar of cornplaion. the Ourner Builder will have the huden of proving tha he or she did not build or irnprove the propoty for the purposc of sale)./ V I. ,. owner of the property. am exclusively contracting with licensed contractors to construct the project (Sec. 7M4, Business and Profession Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon. and who contracts for such projects with a Contracto(s) licansed pursuant to the Contractor's License Law). _l am exempt under Section-. B. orr", DL- //-201h Owner: Yrfok. ny c frrr t, nft Mtt 0 xpr:cLARBil 7 I hereby affinn under penalty of perjury one of the following dcclarationsl _l have and will maintain a Certificate of Consent to Sclf-lnsure for workcrs' compeflsation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which the permit is issued. _l have and will maintain workers' compercation insurance. as required by Section 3700 of the tabor Code, for the po'formancc of the work for which this permil is issued. My workers' comperuration insurance carrier and policy number are: u any person in any manner so as to bccome subject to the workers' compensation laws of California. and agrec that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Codc, I shall, forthwith comply with thosc provisions.. WARNING: Failurc to sccure workers' civil fines up to one hundrcd thousand subject an employer to criminal pcnalties and compcnsation. damages as provided for the Section 3076 of the Labor Codc, interest and attorney's fees. o^rc, Ol -11-,7 0Z h I hereby affirm under penalty of perjury that I am licensed of Chapter 9 (cornmencing rvith Section 7000) of Division 3 of the Business and Professions Code. and my license is in full force and effcct. License Class: License Nurnber: W I hftby affm undq poalty of pcjury thrt th@ is a @nstruclion lcodirg agocy for thc pcfonmcc of thc work for wtich this Frnh b issuod (Se. 3097. Civ. C.). lrndo's Nm€: Lender's Address: APPLTCANT DECLARATION I hereby affinn under penalty of perjury one of the following declarat ions: Demolition Pcrmits-Asbestos Notification Fcderal Regulations (Title 40, Part6) -Required Letter of Notification -l certi$, that the federal regulations regarding asbestos removal are not applicable to this project. y'l certitythat I have read this application and statc that the above infonnation is correct. I with all City and County ordinances and State [,aws relating to building and County to enter upon the above mentioned property for inspection Applicnn( or Agent and hereby o"rc, 0L-ll-2020 Site-Work Underqround Pole Bases Liqht Standards Spas, Pool, Fountains Siqns (monument) Life Safety /Low Voltage Fire AIa rm I Dampers Communications Cable Buildinq Under SIab / Floor Bonding I Grounding / UFER Transformers Torqueing Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rouqh) Ceilings (Hard & Soffit Roush Ceilinqs ff-Bar Rouqh) Jtleter Release Rouqh %t)-*)Lcz t7 Service Meter FINAL //,/?-2D tzco t ta/?og Zt1 Notes, Remarks. Etc. Rev. 08-07-2015 certi$ that in the pcrformance of the work for which this permit is issued, I shall not cmploy Date: Permiree name lprlnt'Sz I OW