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APPROVALS DATE ID/S!G.COMMENTS Site-Work Underqround Pole Bases Liqht Standards Spas, Pool, Fountains Signs (monument) Life Safety /Low Voltage Fire Alarm / Dampers Communications Cable Buildins Under Slab / Floor Bondinq I Groundinq I UFER Transformers Torqueinq Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Roush) Ceilinqs (Hard & Soffit Rouoh Ceilings (T-Bar Rough) Nleter Release Rouqh ,^.. Service N/eter FINAL Q-71 4t ttil 03 Notes, Remarks, Etc. \ OWNI,R BUILDER DIiI,CARATTON I hereby affirnr under penalty of perjury that I am exenrpt from the Contractors' License [:w for thc f<rllowing, rcason (Sec.7031.5 Business and Prol'c.ssion Codc): Any City or County which rcquires a pcrmit to construct, alter. irnprovc. demolish or rcpair any structure, prior to its issuance. also requires the applicant for such Srcrmit to fih a signed statemcnl that lre or she Ls licerrscd pursuant to thc provisions of thc Contractor's Liccnsed law (Chaptcr 9, Commcncing with Section 70fi) of Division 3 of thc Business and Professions Code) or that lr or she is exenrpt therefronr and tlre basis for tlre alleged exenrption. Any violation of Section 7031.5 by any applicant for a pennit subjects thc applicant to a civil penalty of not nnre than five hundred dollars ($5ttO1. _1. as owner ol'thc. propcrty. or my crnployccs with wagcs as thcir sole compcnsation, will do thc work and the structurc is not interxled or offeretl for salc (Scc.7(X+, Business and Professions Codc: Thc Contractor's License Law docs not apply to an owner of the propreay wlxl builds or inrproves thereorl arxl wlro dtrcs such work himself or lrerself or through his or lrer own employees, providcd that such irnproverrcnts are rrlt interxlcd or olTcrcd for salc. Il. howevcr, thc building or inprovennnt is sold within onc )ear of completion, tlrc Owner Builder will have the burden of proving that lr or slrc did not buikl or inprove 0re propary for the purposc of sale). _t.Busincss ard tltereon. and _l anr exenlpt under B. I hercby aflirm under penalty of pcrjury one of tlre tirllowing _l have and will nuintain a Certifrcate of Consent to Self-Insure for workers' compensalion, as provided for by Section 3700 of thc I-abor Code, for the performance of the work for which the permit is issued. _l have and will maintain workers' conpensation insurance, as required by Seclion 3700 of the l-abor Code, for thc pcrfonrunce of the work for which this pcrmit is issued. My workers' comJrcnsation insurance carrier and policy number are: Carrier: Policv Numbcr: Exoires: _l ccrritythat in thc lrcrfornuncc of tlrc work frrr which this Jrcrmit is issued, I shall not cmploy any pcrson in any manner so astobccomc suhjcct tothc workcrs'cornpensation lawsof California. and agree that if I should becotnc subjcct tothc workers' conrlrcnsation provisions of Section 3700 of the Labor Cbde, I shall, forrhwith contply with those provisiotts.. WARNING: Failure to secure workers' compensation coveragc is unlawful, and shall subject an employer to criminal penalties and civil fines up to one lrundred thousand tlollars in addition to tlrc danuges as provided for thc Scction 3076 of the Codc, intcrcst and 4,,, DI.]CT-ARATTON I hereby affirnr under penalty of perjury tlut I anr licensed under provision of Chapter of the llusiness and Professions Code. and my license is in full force and e[fect. 9 (conmrcncing with Sectbn 70m) of Division 3 License Number: CONSTRUCTION LENDING AGENCY I hcreby al'lirm undc'r pcnalty of grcrjury that thcrc is a construction hnding agcrrcy for thc performance of the work lbr which this pcrmit is issued (Sec. 3097. Civ. C.). Lender's Nanre: [rnder'.s Address: APPI,ICA NT DECI,ARATION I hctcby afl-rm undcr pcnalty of pcrjury onc of thc folkrwing dc'cleuations: Dcnplition Pcrnrits-Asbcstos Notification Fctlcral Rcgulations (Titlc 40, Part6) -Rcquircd lrttcr of Notification _l certily that thc fedcral rcgulations rcgarding a-sbestos rcnnval arc not applicablc to this prolxt. _l ccrtify tlral I havc rcad this applicatitxr and stalc thal lhc atxrvc infrrrnulion is corcct. I agrc.e to conply with all City and County ordinanccs and Statc Laws rclating and hcrcby authorizc rcprcscntativcs oflhis City and County to entcr upon thc above mentioned property for Applicant or Agcnt Pcrntilec nanlc *,", tllAf an ELECTRICAL.INSPECTOR RECORD a) '-201 5 tl \\ for \ I