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ELECTRICAL.INSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNI'R BU ILDER DI'I,CARATION I hereby affirnt untler penalry of perjury that I arrr exempt fronr the Contracrors' License Law for the following reason (Sec.lOlt.5 Business and Prolbssion Codc): Any City or County which rcquircs a pcrmit to construct, alter, irnprove. dcmolish or rcpair any structure, prior t<l its issuance. also requires the applicant for such pernrit to fih a signed slate]rEnt that he or she is licenscd pursuant to thc provisions of thc Contractor's l,iccnscd l,aw (Chapter 9, Commencing with Scction 70fi) of Division 3 of thc Business and Professions Code) or that he or she is exenpt therefronr and tlre basis for tlrc alleged exentption. Any violation of Section 7031.5 by any applicant for a Jrcnnit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). _1. as owner of thc property. or tny ernployces with wages as thcir sole compensation, will do thc work and thc struclure is not interxled or offered for sale (Scc.7014. Business and Profcssiorrs Codc: Thc Contractor's License Law does not apply to ur owner of the progrerty wlro builds or inrproves lhererrn, and wlro dtrcs such work himself or herself or through his or her own enrployees, provided that such improvcnrcnts arc not intcrxlcd or ollcred for sah. Il. however, the building or furprovenrcnt is soH within one year of completion, the C)wner Builder will have the burdcn of proving that hc or shc did not build or improve the propcrty for thc purprsc o[ sah). _1. as owner of the property, am exclusively contracting with licenscd contractors to construct thc pmject (Sec. 7044. Business arxl hotbssion Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon. and who contracts for such projccts with a Contracto(s) licenscd pursuant to the Contractor's Licensc taw). -l anr exempt under Section-, B. & P.C. for this reasott. I l^. ... WORKER.S' COM PENSATION DECLARATION I hcrcby affirm under penalty of perjury one of the tbllowing declarations: _l have arxl will nnintain a Certilicate of Consent to Self-lnsure for workers' contpensalion, as provided for by Scction 3700 of the labor Codc, for the performance of the work for which the pcrmit is issued. -l have and will nraintain workers'conryrcnsation insurance, as required by Section 3700 of the l-abor Code, for lhc perfonmrce of which this prmit is is.sued. My Workcrs' compcnsation insurance carrier and gxllicy number arc:( tqfe- ) thc work for f Z-Zl-7cPolicy _l ccrtify tlrat in tlrc lrcrfornuncc of tlrc work f<rr which this pcrmit is issucd, I shall not cmploy any pcrson in any manner so as to bccoryrc subject to the workers' compcnsation laws of California. and agree that if I should beconr subjcct to the workers' conlpensation provisions of Section 3700 of the Labor Code, I shall, forthwith conrply with thosc provisions..( WARNING: Failure to secure workers'compensation coverdge is unlawful. and shall subject an employer to criminal pcnaltics and 'compensation, danuges as provi,.led for lhecivil lines up to one hurdred tlulusand dollars in tlrc cost of Section 3076 of thc [:tnr Crxlc. intcrcst and I)ate:.lo -15'2c I hereby affrnr untler penalty of perjury ttrat I anr liccnscd under provision of Chapter 9 (cotturrcncing with Scction 7000) of Division 3 of the Business and Professions Code. and rny license is in full forcc and effect. License Date: ).,ur", b ticense Number:l.p I Itf- lf'U) CONSTRUCTION LENDING AGENCY I hcrcby aflirrn undcr pcnalty of pcrjury that thcre is a construction hnding agcrrcy for the perlbrrnancc of the work ltrr which this pcrmit is issued (Sec. 3097, Civ. C.). lrnder's Name: APPI,TCANT DECI,ARATION I trrcby affrnr undcr pnalty of prjury onc of the following dcclarations: Dcnxrlithn Pcrnrits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40, Pafl6) -Requircd kttcr of Notification _l certily that thc fedcral rcgulations rcgarding &shstos rennl'al arc not applicablc to this project. _l ccrtily thal I havc rcatl this applicalion urd tlrat ttrc atxlvc inf<rrnution is corrcct. I agrcc to conlply witlr all City and County ordinances and Statc laws rclating and hcrcby authorizc reprcscntatives of this City and County to cnter upon thc above rnentioned properry for Applicant or Agent I'crnritee to building Site-Work Underground Pole Bases Liqht Standards Spas, Pool, Fountains Siqns (monument) Life Safety /Low Voltage Fire Alarm / Dampers Communications Cable Buildinq Under Slab / Floor Bondinq / Groundinq I UFER Transformers Torqueincr Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Roush) Ceilinqs (Hard & Soffit Rouqh Ceilinqs [-Bar Rouoh) Meter Release Rough L',11'A)VEDil,:,*s?8t Service N/eter I I tAl -.? -(* FINAL llPqTc Uf)"t'?0r/, w Notes, Remarks, Etc.I ( Rev. 08-07-201 5 ,