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ELECTRICAL.INSPEGTOR RECORD ,-10 n7 ?n,t A APPROVALS DATE !D/SIG.COMMENTS OWNER BUILDER DELCARATION I haeby affinn unde penalty of pajury that I m erempt ftom the Contracto6' Licffi Law for the follorving rcNn (Se.70l1.5 Buines ud Profsion Codc): Any City or County which require a pei'mit to construct. alte, improvq donolish or rcpair uy structue. pdor lo its isrilce. also requtB the applicot for such pctrnit to filc a signed statmqt thar hc or shc b licqsd pmuill to the provisions of the Contractor's Liccnscd Larv (Chapl6 9. Commcncing with Strtion 7000 of Division 3 of thc Buins ud Prcfsions Code) or that he or she is exonp thrcfrom ild the basis for thc alleged exmption. Any violation of Scctior 7031.5 by any applicantforaptrmilsubj(tsthc applicanltoacivilpenaltyofnotmorcthufivchundreddollus($500). - l. as owner of the f,roperty. or my employees with wages as their sole compensation. rvilldo the work and the structure is not intended or offered for sale (Sec.7044. Business and hofessions Code: The Contractor's License larv does not apply to an orvner of the progr,o'ty rvho builds or improves theron. and who does such $o* himself or herself or through his or her own employees. provided that such improvonents are not intended or offered for sale. If. horvever. the building or imptrovement is sold rvilhin one year of cornplaion. the O'wmer Builder rvill have the bnrrden of proving that he or she did not build or improve the propory for the purpose of sale). _- l. as owner of the property. am exclusively contracting with hcensed contractors to construct the project (Sec. 7U4. Business and Profession Code: The Contractor's License Law does not apply to an ou'ner of property u,ho builds or impro!'es thereon. and s'ho contracts for such projects with a Contracto(s) licensed pursuant to the Contractor's License taw). -.IamexemptunderSection-.B.&P.C.forthisreason. Date:_Ou ner: WORKERS' COIIPENSATION DECLARATION I hseby aflirm undq pcralty of pa'juryone ofthc following deluatioro: -l have md will maintain a Certificate of Coruol to Self-lruure for workm' compcnsation. rc prcvidcd for by Sction -1700 of thc labor Codc for the pcfonnuce of thc wo* for which thc p6mit is i$ucd. 6avc and will rnainlain workm' compcmatiotr imumnce. c requircd by Setion 3700 of the t bor Code. for thc pqfomecc ofI thc work for which this pqmil b isucd. My workc' compcrsaion insumce cmia md policy numbo rc: &a, " .-t lnSr n cu Cr(-aricr: Poricy*,,*,, hV(4 LV L0 l3?lut K _E.rpires: _\ -l cerlify that in the performance of the rvork for rvhich this perrnit is issued. I shall not employ any person in any manner so as to become subject to the rvorkers' cornpensation las's of California. and agrc',e that if I should become subject to the rvorkers' cornpensation provisions of Section .1700 of the l.abor Code. I shall. forthrvith comply rvith those provisions.. WARNIN(i: Failure lo secure workers' compensation coverage is unlarvful. and shall subject an employer to crirninal penalties and civil fines up lo one hundred thousand dollars ($100.000). in addition to the cost of compensation. damages as provided for the Section 3076 (irtle. intercst and attorney's fces.t g) t)t,t('l,AtLt't tON I hereby affinn under penalty of perjury that I arn licenscrl 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. le_l-icense CONSTRUCTION LENDING AGENCY I heeby alfirm unda pcrally of pqjury lhal lhqe is a consrucrion lqding agscy for tho pqfomce of thc work for which this psmil b issucd (56. 1097. Civ. C.). lrnds's Nanc: Lender's Adclress: APPLICANT DECLARATION I hereby allinn under penalty of perjury one of the following declarations: Demolition Permits-Asbcstos Notification Federal Regulations (Title 40. Part6) -Required lrtter of Notification -l cenify that the lHeral regulations regarding asbestos removal are not applicable to this project. _ _l certify that I have read this application and state that the above infonnation is correct. I agree to comply s'ith all City and County : representatives of this City and County to entâ‚¬r upon theordinances and State Larvs relating to construction. and hcreby authorize above mentiond property for Applicnrrl or Agcrrl Signnture: $.- permireename(prinr): gl^EL Site-Work Underground Pole Bases Light Standards Spas, Pool, Fountains Signs (monument) Life Safety /Low Voltaqe Fire Alarm I Dampers Communications Cable Building Under SIab / Floor Bonding I Groundinq / UFER Transformers Torqueing Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Roush) Ceilings (Hard & Soffit Rouqh Ceilings (T-Bar Rough) Meter Release Rough t/ ServiceMeter /^ /tFINAL // {/Jo)a F*/) // Notes Rema Etc. License Class: C,",.,34 IS+ +- \ Contrrctor'(