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ELECTRICAL.INSPECTOR RECORD APPROVALS DATE ID/SIG COMMENTS OWNER BUILDIiR DI',LCARATION . I hereby affrnr under penalty of frlury that I aru exempt from the Clontracton' License law for the foll<lwing reason (Sec.7031.5 Busines.s and Profcssion Crxle): Any City or County which rcquircs a perrnit to construct, altcr. irnprove, dcrmlish or rcpair any slructure, prior to its issuance. also requires the applicurt for such grernrit to fih a signed staternenl that lr or she is licerrscd pursuant to the provisions of thc Contractor's Licenscd law (Chapter 9. Cornmencing with Scction 7fi)0 of Division 3 of thc Busincss and Professions Code) or that lrc or she is exempl therefrom and tlre basis for tlre alleged exenrption. Any violation of Secti<ln 7031.5 by any applicant for a pennit subjects thc applicant to a civil penalty of not nrcre than fivc hundred dollars ($500). _1. as owner ol'thc propcrty. or tny crnploycc.s with wagcs a.s thcir solc compcnsation, will do the work and thc structure is not interxlcd or offercd for salc (Sec.7O$4. Busincss and Professions Code: The Contractor's Licensc l-aw tloes not apply to an owner of the pruperty wlxr btrilds or inproves threon, urd who does such work himself or lrerself or through his or her own employees, provided that such irnprovcnrcnts are not intcndcd or ol'fered for sah. Il. howevcr, the building or furprovenrcnt is sold wilhin one ycar of completioru thc Owner Buil&r will havc the burden of prcving that hc or she did rpt buikl or inrprovc Orc propaty for thc purposc of sale). _1. as owner of the propeny, am exclusively contracting with licenscd contraclors to conslrucl thc project (Sec. 7(X4. Business and Protbssion Code: The Contractor's License lxw does not apply to an owner of prope(y who builds or improves lhereon. and who conlracts for such projccts with a Contractor(s) licenscd pursuant to the Contractor's License Law). _l anr exempt under P.C. lirr this o,r", tllDllro I hcrcby aflirnr undcr pcnalty of pcrjury one of lhc lirllowing -l have and will nnintain a Certificate of Con.sent to Self-lnsure for workers' compensation, as prcvided for by Section 3700 of thc l-abor Code, for the performance of thc work for which thc perrnit is issued. _l have and will nraintain workers' conryrensalion insurarrce, as required by Section 3700 of the l-abor Code, for the Srcrfornunce of the work for which this Jrcrmit is iszucd. My workcrs' conrpcnsation insurance carrier "n l foli.y number are: Policv Number: Exoires: _l ccrtity that in thc lxrlirrnuncc of thc work frrr which this Jrcrnrit is issucd, I shall not cnploy any pcrson in any manncr so as to bccornc subjcct to lhc workcrs' compcnsation laws of California. and agrce that if I shcruld bcconrc subject to thc workers' conrlrnsation provisions of Section 3700 of the Labor Cotle, I shall, forthwith conrply with those provisions.. WARNING: Failure lo secure workers' civil firrcs up lo one hundretl tlmusand is unlawful, and shall subject an cmployer to criminal penahias and , adr,lition to llre cost o[compersation, danuges as provided frlr lhe Scction 3076 of thc [:bor Code, intcrcst and o^.", * lll Dl)..o a DECT.ARATION I hereby affrnr under pnalty of perjury that I anr licens:ed under provision of Chapter 9 (conmrncing with Section 7000) of Division 3 of the llu.siness and Professions Code. and my license is in full forcc and elTect. License Class: License Number: Contrectorl. CONSTRUCTION LENDING AGENCY I hcreby afl'irm undcr pcnalty of pcrjury that therc is a construction lcnding agcncy for thc pcrlbrmance of thc work lbr which this pcrmit is issued (Sec. 3097. Civ. C.). lrnder's Address: APPI,ICANT DECI,ARATION I trreby affrm undcr pnalty of perjury onc of thc following dcclarations: Demolition Perndts-Asbcstos Notification Fedcral Regulations (Tillc 40, Pan6) -Rcquired l,cttcr of Notificatio, \ _l ccrtily that thc fedcral rcgulations rcgarding asbestos rcmoval are not applicable to this profixt. _l ccrtify that I havc rcatl this application turd stalc tlnl with all City and County ordinanccs and Statc Laws rclating to and County to cntcr upon the above rncntioned propcrty for Applicant or Agent I'crnritcc D,'", il/)f Lo Site-Work Underqround Pole Bases Light Standards Spas, Pool, Fountains Signs (monument) Life Safety /Low Voltage Fire Alarm / Dampers Communications Cable Buildinq Under SIab / Floor Bondinq I Groundinq I UFER Transformers Torqueinct Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rouqh) Ceilings (Hard & Soffit Roush Ceilings (T-Bar Rough) l\Ieter Release Rouqh Service lVleter I FINAL ol-zY-A \\L\T Notes, Remarks, Etc.U \ Bev. 08-07-201 5 n lrnder's Name: and hcrcby authorizc rcpresentativcs