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ELECTRICAL.! NSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNER AUILDER DET{NRATION I hqeby aflinn undo penalty of pcjury lhat I m excmpt ftom the ContractoB' Licerc Law for thc following re@n (Se.7011.5 Busines md Profcsion Codc): Any City or County which requirs a permit to costrucl, altc, improvc. dmolish or repair any struclurq prior to its isumce. alm rcquirc the applicul for such pef,nit to lilc a signed stalmot lhd he or shc is licmscd pmuffit to thc provisions of the Contractor's Liccnsed law (Chaptq 9. Commcncing with Setion 7000 of Division 3 of thc Busins ad Prcfsions Codc) or that he or she is cxcmpt thaefrom ud thc basis for thc allcgcd exmption. Any violation of Scuion 7031.5 by any applicantforapcmitsubjCtsthc applicmttoacivilpcnaltyofnotmorethefivehun&cddollus(S500). _1. as owner of the property. or tny employees with wages as their sole cornpensation. willdo the work and the structure is not interrded or offered for sale (Sec.7044. Business and hofessions Code: The Contractor's License larv does not apply to an owner of the property who builds or improves thermn. and who does such $'od( himself or herself or through his or her own employees. provided that such irn;novanents are not intended or offerod for sale. ll. how'evcr. the building or improvement is sold within one )rear of cornplaion. the Orvner Builder will have the h.rden of proving tha he or she did not build or improve the propoty for the purpose of sale). ___1. as owner of the property. arn exclusively contracting rvith licensed contractors to conslruct the project (Sec. 7M4. Business and Profi:ssion Code: f'he Contractor's License Lau' does not apply to an owner of property rvho builds or improves thereon. and rvho contracts for such projects rvith a Contracto(s) licensed pursuant to the Contractor's License [arv). _l arn exempt under Section_ . U. & P.C. for this reason. Dnte: Owner:u'tx D!:( l,ARA'TION the follorr ing dcclarations:I hereby affrrm under penalty of perjury one of -l havc ard will miotain a Ccnificatc of Co|lmt to Self-lNure for workss' compwtion. r prcvidcd for by S6tion 3700 of thc Labor Codc for the pcfonnmcc ofthc work for which thc pqmit is issued. Sauc and *itl naintain workm' compcmation imurancq 6 rcquircd by Sction 37OO of thc Lrbor Codc. for thc pqfomuce of' thc wor* for which this p6nit is iscd. My workm' compcr, aion imuroic cmiq ud polky numbo ac ' A l^u(zP cr n C-Q C-- -Expires, + /r /a o .Policy Number:+t\ E _l ccrti$ that in the pcrforrnance of the rvork for r+'hich this pennit is issued. I shall not employ any person in any manner so as to becorne subject to the workers' compensation lan's of California. and agree that if I should become subject to the rvorkers' compensation provisions of Section 3700 of the Labor Code, I shall. forthrvith cornply with those provisions.. WARNING: Failure to secure workers' compensation coverage is unlarvful. and shall subject an enrployer to crirninal penalties and civil fines up to one hundred thousand dollars ($100.000). in addition to the cost of compensation. damages as provided for the Scction -3076 of the Labor Code. interest and attorney's fecs. Dnte: I \I Otl lr\'\- I DECLARATION I hereby affirm under penalty of perjury that I am licensed under provision of Chapter 9 (commencing rvith Section 7000) of Division 3 of the Business and Professions Code. and my license is in full force and effect. License Ctass, C /t O oete:1/aolS \ contrecror: &a-YSt \;- T T CONSTRUCTION LENDTNG AGENCY I hrcby affm undr pcnalty of pcdury thst th@ is a construction knding agacy for the pqfomilcâ‚¬ of the work fur which this prmit b issucd (Se. 3097. Civ. C.). bnd6's Nme: Lender's Address: APPLICANT DECLARATION I ho*y affinn under penalty of perjury one of the following declarations: Demolition Perrnits-Asbestos Notification Federal Regulations (Title 40. Pan6) _Required Lrtter of Notification _l cstify that thc fcderalregulations rcguding cbctos rmoval ae not applicable to this prcjâ‚¬t. -l cqrify that I havc rad this application ild slatc that thc abovc infomaion is coqcct. I agre ro complywith all Cityand County ordinancc ud Statc Law rclaing to building consruaion. ud haeby authorizc rcprMtativc of this City md County to ots upon thc abol'e rnentioned property for Applicurt or Agenl I'ernrilee nnme (print): pats [ ) Site-Work Underground Pole Bases Light Standards Spas, Pool, Fountains Signs (monument) Life Safety /Low Voltage Fire AIarm I Dampers Communications Cable Building Under Slab / Floor Bonding I Groundinq / UFER Transformers Torqueinq Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rouqh) Ceilinss (Hard & Soffit Rouqh Ceilings (T-Bar Rough) Meter Release Rough ServiceMeter /^ /I FINAL Etc. f)n'7 '>^a F,