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ELECTRICAL.I NSPECTOR RECORD APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION I hceby affm undo poalty of pcrjury that I an qmpt fiom the ContretoB' Licffi [rw for the following l@n (Se.7031.5 Busines and Profsion Code): Any City or County which rcquire a pomit to @nstruct, alt6, improvq &molish or npair uy structue, prior to its isumcc, also rcquirc thc applicnt for such pcmit to filc a signcd stat@flt that hc or strc is licqEcd puMt to the Fovisioru of thc Contretor's Licascd t:w (Chapt6 9, Comocing wilh Setion 7000 of Division 3 of thc Buine ud Prcfsions Code) or thal hc or she is cxmpt thqefrom od thc bssis for the allcged cxanption. Any violalion of Setion 7031.5 by any applicantforapmitsubjctsthc applicanttoacivilpenaltyofnotmorcthmlivchundrcddollus($500). _1. as owner of the property, or my employecs with wages as their sole cornpensation. will do the work and the structure is not intendod or offered for sale (Sec.7M4. Business and Professions Code: The Contractor's License Law does not apply to an owner of the propaly who builds or improves thereon. and who does such work himself or herself or through his or her own employees. provided that such irnproveinents are not intended or offsed for sale. If. howwer. the building or improvement is sold within one )ear of completion, the Or,vner Builder will have the burden of proving tha hc or she did not build or improve the property for the purpose of sale). _1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professbn Codc: The Contractor's License Law does not apply to an orvner of property who builds or improves thereon. and who contracts for such projects with a Contracto(s) licensed pursuant to the Contractor's License Law). -l am exempt under Section-, B. & P.C. for this reason. f )o to' WORKEITS' COMPENSATION DECLARATTON I hereby affrnn under penalty of pe'jury one of the following declarations: -l have and will rnaintain a Cerrificate of Consent to Self-lnsure for workcrs' compensation, as provided for by Se<tion 3700 of the Labor Code. for the performance of the work for which the perrnit is issued. -l have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this pennit is issued. My workers' compensation insurance calricr and policy numh are: ftnl ( ico, 14 ?Vr tC h I cL-Policy _l certify that in the perforrnance of the work for which this perrnit is issued. I shall not employ any person in any manner so as to becornc subject to the workers'compensation laws of California, and agree that if I should become subject to the . workers' compensation provisions of Section -1700 of thc Labor Code. I shall. forthwilh comply with those provisions.. WARNTNG: Failure to secure workers' compensation coverage is unlawful. and shall subject an onployer to criminal penalties and civil fines up to one hundred thousand dollars ($100.000). in addition to thc cost of compensation, damagcs as provided for thc Section 3076 of the Labor Code. interest and attorney's fees. LICT'NSED CONTRACTOR DECI.,ARATION I hereby affirm under penalty of pcrjury that I am licensed under provision of Chapto 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. lo Numbcr:a) t7 ia Dete: L-14-7aCO \/?Vin+ Sot CI l- W I hwby alfim unda pcnalty of pqjury that thft is a @mtruclion landing agocy for thc pofommcc of thc work 6r wfiich this psmit b issucd (Se. 3097. Civ. C.). [ender's Name: I-cnder's Address: APPLICANT DECLAIIATION I hodry affirm under penalty of perjury onc of thc following dcrlarations: Demolition Perrnits-Asbcstos Notification Federal Regulations (Title 40, Par16) -Rcqu ired Lettcr of Notification -l cqtiry that the fcdgal rcBulatioE rcgeding sbetos moval rc mt applicsblc to this prcj@t. [!1t cqriry tur t twc ud this applicalion ad statc thar thc 8bovc information is con61. I agre to omply with atl Chy md Couty ordimc md Statc lrws rclathg to building coEtructioG ald hreby suthorie rcprMtsriv6 of this City ud Couly to at6 upon thc il-":ffil.T on" z-4- ? e>?o l'ermitee nrme (print):lDanin ItQrzd ) Site-Work Underqround Pole Bases Light Standards Spas, Pool, Fountains Signs (monument) Life Safety /Low Voltase Fire Alarm lDampers Communications Cable Building Under SIab / Floor IT ,l - -/, Bonding I Groundins / UFER 91q20 (w6Y Transformers ,,t0- Torqueing Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Roush) Ceilings (Hard & Soffit Rough Ceilinqs ff-Bar Rouqh)\-/) -t Meter Release .4%ltD LY6- I I I I Rouqh Service Meter tt -a FINAL 1c117t)Dlt\fY CI Etc. Rev. 08-07-2015 I License Class:. v{tfl- /Tr - I 'l