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ELECTRICAL-INSPECTOR R ECORD APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hercby affum undcr pcnalty of pcrjury thal I m cxempt frcm lhe Contracton' License [aw for the following rcasn (Src.7031.5 Busincss and Profcssion Code): Any City or Counly which rcquircs a pcrmit to construct. lltcr. imprcve, dcmlish or rcJEir any structurc. prk)r to its issudcc, also rcquircs thc applicot for such lrmit to lilc I sigred slatcrEnl lhat he or she is liccnsd pmunt to thc prcvisions of thc Contractor's Liccnsd kw (Chaprcr 9, ColmrcinS with S$tion 700O of Division 3 of thc Busircss and ProfcssionsCodc)orthathcorshciscxemptthrcfromandthcbasisfortheallcgedcxctr{rtion. AnyviolationofsedhnT03l.5bysny opplicant for a permit subjcts thc applicant to r civil penalty of not mrc Ihan fivc hundrcd dollrs ($500). _1. as owncr of thc propcrty. or my cmployces with wages as thcir solc comfrcnsalion. willdo thc work and thc slructure is not intcrxlcd or offercd for sale (Scrc.?O44. Busirrcss and hofcssions Codc: The Contraclor's Liccnsc l-aw docs not apply lo an owncr of thc pmprty who huilds or inrprovcs thcrmn. arxl who docs such work himsclf or hcrsclf or through his or hcr own cntployees. providcd that such irnprovcrncnts arc not intcndcd orolTcrcd for salc. lf. howevcr, thc building or improvcrpnt is sold within onc ycar ol'conrplction. thc Owncr Buildcr will have thc burden of proving that hc or she did not build or improve thc propcrly for thc purynsc of salc). _1, as owncr of thc property, am cxclusivcly contracting with licenscd contractors to construct ttrc projcct (Scc. 7(H. Busincss and Profession Codc: The Contraclor's Liccnsc Law docs not apply lo an owner of property who builds or improvcs thereon. und who contracls for such projccts with a Contractor(s) liccnscd pursuant to thc Contractor's Liccnsc taw). _l anr excnrpt undcr B. & P.C. for this rcason. I)llc ()rvrtcr: WORKERS' COMPENSATION DECLARATION I hcrcby affirm undcr penalty of pcrjury one of thc following dcclarations: _l havc and will rnaintain a Ccrtificatc of Consent to Self-lnsurc for workers' compcnsation. as provided for by Section 3700 of thc I",abor Code, for thc pcrformancc of thc work for which thc pcrmit is issucd. _l have and the work for will rnaintain ils by Scction 3700 of thc labor Codc. for thc pcrformancc of lhis carricr and plicy numbcr are: 1I)olicy _l ccrtify that in thc lrcrforrnancc of the work for which this Jrcrrnit is issucd, I shall not employ any frcrson in any manncr so as to beconrc subjcct to thc workcrs' compcnsation laws of California, and agrcc that if I should bcconr subpct to thc workcrs' compcnsation provisions of Scction 3700 of the hbor Codc. I shall. forthwith comply with thosc provisions.. WARNING: Failurc to sccurc workcrs'compcnsation covcragc is unlawful. and shall subjcct an cmploycr to criminal pcnaltics and civil fincs up lo onc hundrcd thousand dollars ($100,000). in addition to damagcs as providcd for thc I hcrcby afl-rm undcr penalty of prjury that I am liccnrd undcr provision of Chaptcr 9 (commcncing with Section 7000) of Division 3 of the Busincss and Profcssions Code, and my license is in full force and effcct. ) [-iccnsc 4l\1 I hcrcby affirrrr undcr pcnalty of perjury that issucd (Sec. 3097. Civ. C.). lrnder's Namc: CONSTRUCTION LENDING A(:ENCY therc is a construction hnding agency for the pcrfonnance of the work for which this pcrmit is rD Lcndcr's Addrcss: APPI ICANT TTECI ^RATION I trcrcby aftirm under grcnalty of prjury one of thc following declarations: Dcnrolition Pcrmits-Asbestos Notification Fcderal Regulations (Title 40, Part6) _Rcquircd l-cttcr of Notification _l certify that lhc federal regulalions regarding asbestos rcmovalarc nol applicablc to this project. L _l ccrtify that I have read this application and statc that thc inforrnation is corrcct. I agrcc to cornply with all City and County ordinanccs and Statc Laws rclating to building abovc mcntioned proprty for Applicant or Agent I'ernrilee nanle authorizc of this City and County to cnter Site-Work Underqround Pole Bases Liqht Standards Spas, Pool, Fountains Siqns (monument) Life Safetv /Low Voltaqe Fire Alarm / Dampers Communications Cable Buildinq Under SIab / Floor Bondinq I Groundino I UFER Transformers Torqueinq Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rouqh) Ceilinqs (Hard & Soffit Rouqh Ceilings (T-Bar Rouqh) JMeter Release Rough suLJtn-4-t?t-- e 4z Service lt/leter FINAL 4-1'?r D'^/{z Notes, Remarks, Etc. Dnr nQ n7 r)n1 tr _Expircs: Scction [-rbor Applicant: