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OWNER BUILDER DELC'ARATION I hceby alfum unds pcrulty of pcrjury thar I m cxempt from thc Contractos' Licw Law for thc follorving rcon (5{.7031.5 Businss and Profsion Codc): Any City or County rvhich rcquire a pemit to @Nlruct. altc, improvc. dmolish or repai: a:v structua prior to its isumcc, also rcquira thc applicat for such pernit to filc a signed statmot tha hc or shc b licmcd pusmt to thc provisioN of the Contractor's Liccnscd trw (Chapto 9. Commcncing u'ith Sction 7000 of Division 3 of the ltusine md Prcfesions Code) or that he or she is cxempt thqefrom ild thc basis for thc allegcd cxmption. Any violation of Sstion 70-l L5 by any applicetforapcnnitsubjetsthc applicanttoacivilpmaltyofnotmorcthafivchundrcddollus($500). _1. as owner of the proprerty. or my employees with rvages as their sole compensation. willdo the work and the structure is not intended or offered for sale (Sec.7M4. Business and Professions Code: The Contractor's License Larv does not apply to an owncr of the property who builds or improves theron, and who does such work himself or herself or through his or her own employees. provided that such improvonents are not intended or oflered for sah. I[, horvet/â‚¬r. the building or improvement is sold within one year of complaion. the Orvner Builder will have the burden of proving that he or shc did not build or improve the propoly for the purpose of sale). _1. as owner of the propcrty. am exclusively contracting rvith licensed contractors to construct the project (Sec. 7044. Business and Profession Code: The Contractor's License Law does not apply to an owner of properly who builds or improves thereon. and who contracts for such projects rvith a Contractor(s) licensed pursuant to the Contractor's Liccnse taw). -l am exempt under Section-. B. & P.C. for this reason. Date:_ I hereby alTirm under penalty of perjury one of the following declarations: -t have and will rnaintain a Certificate of Consent to Self-lnsure for rvorkers' compensation, as povided for by Section 3700 of the Labor Code. for the perfonnance of the work for which the pennit is issued. --l have and will maintain workets' compensation insurance. as required by Section 3700 of the labor Code. for the perfonnance of the work for which this permil is issued. My rvorkers' compensation insurance carrier and plicy number are: c*| ,, fi(wLv\ [hn alvlcl^ Poricy Nr,rb*,' W(-qMlJC O b t\ -Expires: I q I r lt-o _l certify that in the perfonnance of the work for rvhich this permit is issued. I shall not employ any person in any mantlcr so astobecomesuhje,cttothervorkeis'cornpensationlarvsofCalifornia.andagreethatiflshouldbecomesubjecttothe rvorkcrs' compensation provisions of Section 3700 of the l-abor Code. I shall. forrhrvith cornply rvith those provisions.. WARNTNG: Failure to secure norkers' compensation co!'erage is unlan'lul. and shall subject an to criminal perulties and civil fines up to one hundred thousand dollars in addition to the of as provided for the Section -1076 of the Labor Code. interest and 4 I hereby affrrm under penalty of perjury that I zun licensed 9 (commencing with Section 7000) of Division -3 of the Business an{ Professions Code, and my license is in full force and effcct. ( :-4 License Date: L-'License Number: \-Ll4 I tq aon,*\A%: W I h6eby affim unds pcnalty of pojury tha thoc is a coBtruction ldding agmcy for thc perfomecc of thc sork fot which this pqmit is issued (Sec. 3097. Civ. C.). [.ender's Name: Lentler's Address: APPLICANT DECLARATION I hereby allirm under panalty of perjury onc of the follorving declarations: Demolition Permits-Asbcstos Notification Fcderal Regulations (Title 40. Part6) -Required Letter of Notification _-_l cerrifu that the fbderalregulations regarding asbestos removalare not applicable to this projecl. certify that I have read this application and state that the above I agree to comply with all City and County and State Larvs relating to building and of this City and County lo enter upon the above mentioned property for Applicnnt or Agent ilnt",zl qltq l'crnritee nAnle (print):__ APPROVALS DATE ID/SIG.COMMENTS Site-Work Underground Pole Bases Light Standards Spas, Pool, Fountains Signs (monument) Life Safety /Low Voltase Fire Alarm I Dampers Communications Cable Building Under Slab / Floor Bonding I Grounding / UFER Transformers Torqueinq Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rouqh) Ceilings (Hard & Soffit Rouqh Ceilings (T-Bar Rough) Meter Release Rough Service Meter I 7/zZ/"//,F!NAL 'D /r#Qt) Notes, Remarks, Et6. / I >A A ()^' ELECTRICAL.! NSPECTOR RECORD \-7 )n -r, -- Cro