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ELECTRICAL.INSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DE,LCARA'TTON 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, dennlish or repair any structure, prior to its issuance, also requires the applicant frlr such permit to file a signed staternent that he or she is licensed pursuant to the provisions of the Contractor's Licensed Uaw (Chapter 9, Commencing with Section 7ff)O of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a lrcrrnit subjects the applicant to a civil penalty of not rrnre than five hundred tlollars ($5ttO1. _1. as owner of the property. or my empkryees with wages as the ir vrle compensation. will do the work and the stnrture is rxrt intentled or offered for sale (Sec'.7(X4, Business ancl hofessions Ctxle: Thc Contractor's License Law does not apply to an owner of the property who builds or improves thercon, arul who drxs such work himself or herself or through his or her own employees, provitled that such improvenrnts are not interxletl or offeral for sah. If, tnwever. tlre buikiing or inprovenpnt is sokl within one )tar of cornpletion, the Owner Buikler will have tlre burden of proving that he or she did not buikl or improve the property for the puryxrse of sah). _1. asownerof the property, amexclusively contracting with licensed contractoni to construct the pnrject (Sec. 7(X4, Business and hofessirnCode: TheContractor'sLicenseLawtloesnotapplytoanownerofpropertywhobuildsorimprovesthereon. and who conlracts frrr such projects with a Contracto(s) licensed pursuant to the Contractor's License Law). -IanlexenrptunderSection-,B.&P'C'forthisreason.Owner:- WO RK ERS' CONT I'L,NSA'I'ION DI,CLARA'I'I(}N I hereby affirrn under penalty of perjury one of the following tleclarations: _l have and will maintain a Certificate of Glnsent to Self-lnsure filr workers' compensation, as provided for by Section 3700 of the Labor Code. for the Jrerfornunce of the work for which the prmit is issued. _l have and will maintain workers'compensation insurance. as required bySectionlT00of the LaborCode, forthc perfrrrmanceof the work for which this prmit is issued. My workers' compensation insurance carrier and plicy number are: Policy Number: Expires: _l certify that in the perfirrmance of the work frrr which this perrnit is issued. I shall not empk)y any person in any mtyrcr so as to become suhject to the workers'compensation laws of California, and agrce that if I should become subject to the workers' compensation provisions of Section 3700 of the latxrr Cotle. I shall. forthwilh cornply with those pnrvisions.. WARNING: Failure to secure wrlrkers'compensation coverage is unlawful. and shall subject an empkryer to criminal penalties and civil fines up to one huntlred thousand dollars ($100,000). in adtlition to the cost of com[rcnsation. damages as provided for the Section 3076 of the Lahlr Code, interest and attorney's fees. Date: Appllcant: LIC ENS},D C(IN'I'RAC'I'(UI DF.CLAR,\'l'l0N I hercby affirm under penalty of perjury that I am licensed under provision of Chapter 9 (comrnencing with Section 7firc) of Division 3 of the Business and Professions Code, arxl my license is in full force arxl effect. License Class: License Number: Date: CONST'RUC'I'ION LENIIING AGIiNCY I hereby aflirm under penalty of perjury that there is a construction hnding agency for the perfonnance of the work frlr which this prmit is issued (Sec. 3097, Civ. C.). Lentler's Nrme: Lender's Address: AITDLICAN'I DEC LARATION I hereby affrnr under penalty of perjury one of the folklwing declarations: Demolition Permits-Asbestos Notification Federal Regulations (Title 40. Part6) -Required Letter of Nrlification -l certify that the federalregulations reganling asbestos renrovalare not applicable to this project. -l certify that I have read this application and state that the ahrve inftrrnration is conect. I agree to comply wilh all City and County onlinances and State Laws relating to building construction, and hereby authorize representatives of this City and County to enter upon the atxrve nrcntioned property frrr inslrcction purposes. Applicant or I'ermitee name (print):_ I 1...,.. Site-Work Underground Pole Bases Liqht Standards Spas, Pool, Fountains Signs (monument) Life Safety /Low Voltage Fire Alarm I Damoers Communications Cable Building Under Slab / Floor Bondins / Groundinq I UFER Transformers Torqueinq Sub-Panels Air Conditioners Roof Top Equipment Factorv Wired Unit Walls (Conduit) Walls (Rough) Ceilinss (Hard & Soffit Rouqh Ceilinss (T-Bar Rouqh) N/eter Release Rouqh Service N/eter tl I FINAL 0 llL\9kw6 t, / Notes, Remarks, Etc.I Flev. 08-07-2015 Date: