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ELECTRICAL-INSPECTOR R ECORD APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDUR DELCARATION I hereby affirm under penalty of perjury that I am exempt from the Contractors' License Law for the following reason (Sec.7031.5 Business and Profession Code): Any City or County which requires a permit to construct, alter, improve. denrolish or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that hc or she is licensed pursuant to the provisions of the Contractor's Licensed I-:w (Chapter 9, Commencing with Section 70fi) of Division 3 of the Business and Prcfessions Cotle) or that he or she is exempt therefrom and the basis firr the alleged exemption. Any violation of Section 7031 .5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred tlollars ($5001. _1. as owner of the pmf,erty. or my employees with wages as their srle compense[bn, willdo the work arxl thc structurc is mrt interrled or offered for sale (Sec.70t4, Business and hofessions Cule: Thc Contractor's License Law does not apply to an owner of tlre pmperty wln builds or impnrves therann, arxl wlxr dtres such work himself or trerself or through his or her own employees. provided that such improvernents are not intended or offercd for sah. lf, hlwever, the building or improvenrnt is sold within one year of completion. the Owner Buikler will have the burden of proving that he or she di<J not buikl or improve the pnrprty for the purprse of sale). _1. as owner of the property. am exclusively contracting with licenscd contractors to construct the pmject (Sec. 7(X4, Business and hofession Ctxle: The Contractor's License Law does not apply to an owner of proprty who builds or improves thereon. and who contracts for such pmjects with a Contracto(s) licensed pursuant to the Contractor's License Law). -l amexempt under Section-, B. & P.C. for this reason. Date: Owner_ WORKERS' COMT'ENSATION DECLARA'I'ION I hereby affirm under penalty of perjury one of the following declarations: _l have antl will maintain a Certifrcate of Consent to Self-lnsure for workers' compâ‚¬nsation. as pnrvided for by Section 3700 of the [-atx:r Code, for the Jrerformance of the work for which the permil is issued. _lhaveandwill maintainworkers'compensationinsurance,as requiredbySection3Tfi)oftheLaborCode,fortheperftrrmanceof the work which this permit is issued. My workers' compensation insurance carrier and policy number are:t\lrilz.Policy c 3 _l certify that in the performance of the work for which this permit is issued, I shall not ernploy any person in any manner so asto becorne subject to the workers'compensation laws of California, and agree that if I should become subject tothe workers' compensation provisions of Section 3700 of the labor Ctxle, I shall, forthwith comply with thosc pnrvisions.. WARNING: Failure to secure workers' compensation coverage is unlawful, and shall suhject an employer to criminal penalties and civil fines up to one hundrerl thousand dollars ($lm.Un), in addition to the cost of compensation. damages as provided ftrr the Section 3076 the Lahrr Code, interest and attorney's fees. L DECLARATION I hereby affirrn under penalty of perjury that I am licensed under provision of Chapter 9 (comrnencing with Section 7m0) of Division 3 of the Business and hofessions Code, and my license is in full force and effect. License 4b &Nurnber:3QQ CONS'TRUCTION I I'NIUNG AGtsNCY I trcreby affirm under penalty of perjury that there ls a construction lending agency for the performance of thc work for which this prmit is issued (Sec. 3097. Civ. C.). lrnder's Name: Lender's Address: AI'PLICANT DECLARATION I trreby affirrn under pnalty of prjury one of the following declarations: Demolition Permits-Asbestos Notification Federal Regulations (Title 40, Pan6) -Required Letter of Notification _l certify that the federal regulations rcganling asbestos rentrval are not applicable lo this project. _l certify that I have read this application and state that the atxrve all City and County onlinances and State Laws relating to enter upln the atxlve rnentioned property for inspection Applicant or Agent l'rnnitee name imd z( Site-Work Underoround Pole Bases Liqht Standards Spas, Pool, Fountains Siqns (monument) Life Safetv /Low Voltaqe Fire Alarm / Dampers Communications Cable Building Under Slab / Floor Bondins / Groundinq / UFER Transformers Torqueinq Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Wails (Roush) Ceilinqs (Hard & Soffit Rouqh Ceilinqs (T-Bar Rouqh) lVleter Release Rough Service Meter t,I FINAL qh/%-l*r^ Notes Remarks Etc. I Rev. 08-07-201 5 D a is correct. I representatives