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APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcrcby uflirm under pcnahy of pcrjury that I m cxcmpt fmm thc ContracloF' Licenre kw for thc followitrg rcamn (Sc.7031.5 Busincss and Profcssion Code): Any City or County which rcquircs s lEnnit lo construcl. alts. improve. dcmolish or rcJnir any slructure. prior lo its issume, als rcquircs the .pplicanl for such Frmit to lih a sigred statemnt that hc or shc ir liccnscd pusuant to rhc pmvisions of tlE Conracbr's Licenmd [:w (Chaptcr 9. Comnrcncing wilh Sslion 7000 of Division 3 of lhe Busincss and Prcfcssions Codc) or that hc or shc is cxcmpt thcrcfion and thc basis for thc alhgcd cxcmption. Any violation of Sethn 703 1.5 by any applicant for a Frmit subjects the applicant to a civil pcnalty of not mrc than five hundrcd dollds ($500). _1. as owner of the propcrty, or my employces with wagcs as thcir stllc comfrcnsation. will do the work and the structurc is not interded or offcrcd for salc (Sec.7044. Business and hofessions Culc: Thc Contractor's Licensc [,aw does not apply to an owncr of thc propcrty who builds or improvcs thcreon. and who docs such work himsclf or hcrself or through his or her own cmployces. providcd that such improvenrcnts are not intcnded or offercd fbr salc. Il. txlwcvcr. thc buikling or inrprovcnrcnt is sold within onc )aar of comphtion. the Owncr Buildcr will have thc burden of proving that hc or shc did not build or improve thc propcrty fbr thc purpsc of salc). _1, as owncr of the propcrty, am exclusivcly contracting with liccnscd contractors to construct the projcct (Scc. 7lW. Busincss and Protbssion Code: Thc Contraclor's Liccnse Law does not apply to an owner of property who builds or improves thcrcon. and who contracts fbr such projccts with a Contractor(s) liccnscd pursuant to thc Contractor's Licensc Law). -IatttcxclnptundcrScction-.t].&P.C.tbrthisrcason.Date:_Owner:_ WORKF'RS' COMPENSATION DEC] AIIATION I hcrcby ufljrm under pcnalty of pcrjury onc of the tilllowing dcclarations: -l have and will maintain a Certificatc of Conscnt lo Self-lnsurc for workcrs' comyrcnsation, as provided for by Section 37fi) of thc Labor Codc. for the lrcrformance of the work for which thc pcrrnit ls issucd. &.bor" and will maintain workers' compcnsation insurancc. as rcquircd by Section 3700 of thc L-abor Codc. for the pcrfornuncc of thc work for which this permit is issued. My workcrs' comlrcnsation insurancc carricr and plicy numbcr arc: Policy o /-7/-27 _l ccrtily that in thc Jrcrformancc of thc work for which this prnrit is issucd. I shall not employ any person in any manner so as to bccomc subjcct to thc workers' compcnsation laws of California. and agrce lhat if I should bcconrc subjcct to the workcrs' conrpensation provisions of Scction 3700 of thc Latnr Codc. I shall. forthwith comply with those provisions.. t WARNING: Failurc lo sccurc workcrs' cornpcnsation covcragc is unlawlul. and shatl subjcct an cnrploycr tch'iminal Jrcnaltics an<l thousand dollars ($100,0U11, in addition to thc cost of compcnsation, darnage's..',s providcd lirr thccivil tincs up to hundrcd Scctiun 3076 intcrcst antl attorncy's l'ccs., C DT'CI ,IRATION I hcrehy afflrm under pcnalty of pcrjury that I am liccnscd undcr provision of Chaptcr 9 (conrmcncing with Section 7m0) of Division 3 of thc Busincss and Professions Codc, and nry liccnsc is in full forcc and cffcct. Liccnsc -r-Nunrhcr:?- W I hcrcby affum undcr pen8lly of pcrjury that thcrc is 8 conslructbn lcnding agcrcy for the pcrforue of the work for which this Fmil ir issucd (Ss. 3097, Civ. C.). lxnder's Nam: lrndcr's Addrcss: APPLICANT DTCLARATION I hcrcby affinn undcr pcnalty of pcrjury onc of thc ltlllowing dcclarations: Dcnrolition Pcrmits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40. Part6) _Rcquircd lrtter of Notification _l ccrtily that thc fcdcral rcgulations regarding ashcslos rcrrloval arc trot applicahlc to this project. _l ccrtity that I havc rcad this application and stale is corrccl. I agrcc to comply with all City and ordinanccsarrd Stalc Laws rclating to building atxlvc rncntioncd propcrty tbr inspcction Applicant or Agcnt Permitee nanre ( authorizc represcntativcs oIthis City and County thc Site-Work ( Underground ,-l?7(/2Zz rr7 Pole Bases Liqht Standards ^l Spas, Pool, Fountains ?t2zl lLf-/t I Signs (monument) Life Safety /Low Voltaqe Fire Alarm / Dampers Communications Cable Building Under Slab / Floor Bondinq I Groundins I UFER Transformers Torqueinq Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rouqh) Ceilinss (Hard & Soffit Rouqh Ceilinos [-Bar Rouqh) Meter Release Rouqh Service N/eter FINAL lo'54a *,**Ll2- Notes, Remarks, Etc. \ ELECTRICAL.INSPECTOR RECORD no n7 /^,n1 trf,Jnr Ap;llicnnl: "-/