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APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDb,R DELCARA'I'ION I herehy affirm untler penalty of perjury that I arn exempt fnrm the Contractors' License Law for the following reason (Sec.7031.5 Business arxl Profession Crxle): Any City or County which requires a prmit to construct, alter, improve. tlennlish or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed staternent that he or she is licensetl pursuant to the provisions of the Contractor's Licensed Law (Chapter 9. Commencing with Section 7fi)0 of Division 3 of the Business and Professions Cotle) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031 .5 by any applicant for a permit subjects the applicant to a civil penalty of not nx)re than five hundred dollars ($5tXl). _1. as owner of the property. or my empkryees with wages as their srle compensation. will do the work and the structurc is not intended or offered ftrr sale (Sec.7(X+, Business and Professions Ccxle: The Grntractor's License L:w does not apply to an owner of the pmperty who builds or improves thercon. and who ckres such work hirnself or herself or through his or her own emphyees, provided that such improvements are not intemled or offeral for sale. If, however. the buikling or inprovenrnt is sokl wihin one )rar of completion, the Owner Buikler will have the burtlen of pnlving that he or she tlid not buikl or imprcve the pruperty for the purynse of s:lle). -1, asownerof theproperty, amexclusivelycontracting with licensed contractorstoconstruct the project (Sec.7M4, Business and hofessi-ln Code: The Contractor's License Law does not apply to an owner of progrcrty who builds or improves thereon, antl who contracts for such pnrjects with a Contractor(s) licensed pursuant to the Contractor's License Law). -IamexemptunderSection-'B.&P.C.forthisreason. Date: WORKERS' COM PD,NSA'TION Dk'cLAlLd'iloN I hereby affirnr un<ler penalty of perjury one of the following declarations: -l have and will maintain a Certihcate of Consent to Self-lnsure for workers' compensation, as provitled for by Section 37fi) of the Labor Code. for the performance of the work for which the permit is issued. -l have and will maintain workers' compensation insurance, as required by Section 37fi) of the Labor Code, ftrr the performance of the work for which this permit is issuetl. My workers' compensation insurance carrier and gllicy number are: Carrier: Policy Nurnber: Expires: -l certify that in the performance of the work ftrr which this permit is issued, I shall not employ any person in any melnner s() as to beconp subject to the worliers'comflensation laws of California. and agrce that if I shoukl become subict to the workers' compensation provisions of Section 37ffi of the Lahlr Ccxle, I shall, frrrthwith cornply with those pnrvisions.. WARNING: Failure to secure workers' compensation coverage is unlawful, and shall subject an employer to criminal penalties and civil fines up lo one hundred thousand dollars ($l00.Un), in addition to the cost of compensation, damages as provided for the Section -3076 of the Lahlr Cule, interest and attorney's fees. Dete:A nnlir.onl. LICE,NSED CONTRACTOR IDF,CLARATION I hercby affrm under penalty of perjury that I am licensal untler provision of Chapter 9 (comnrcncing with Section 7Un) of Diviqion 3 of the Business and hofessions Code. and my license is in full force arxl effect. a License Number: CONSTRUCI'ION LENDING AGENCY I hereby affirm under penalty of perjury that there is a construction lending agency for the perfrrrmance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name: APPLICANT DECLARATION I hereby affnm under pnalty of Jrerjury one of the following declarations: Dennlition Perrnits-Asbestos Notification Federal Regulations (Title 40, Part6) -Requ ired Lrtter o f Notifrcation -l certify that thc federal regulations rcgarding asbestos rernrval are not applicable to this project. -l certify that I have read this application and state that the ahrve information is correct. I agree to comply with all City and County ordinances and State Laws rclating to building construction, and hcreby authorizr representatives of this City and County to enter ufnn the above rnentioned property for inspectir)n purposes. Applicant or l'rrrtritrr n:rnrc (;lrilrl l: Site-Work Underqround Pole Bases Liqht Standards Spas, Pool, Fountains Siqns (monument) Life Safety /Low Voltaqe Fire Alarm / Dampers Communications Cable Building Under Slab / Floor Bonding / Groundins I UFER Transformers Torqueincr Sub-Panels Air Conditioners Roof Top Equipment Factorv Wired Unit Walls (Conduit) Walls (Rough) Ceilings (Hard & Soffit Rouqh I ///^,1/ Ceilinss (T-Bar Rouqh)7/dfl,i//ftu*Z ,%Jf1 l\Ieter Release t/ Rouqh //Ir Service Meter / q/+///K-n FINAL (7tD Notes, Remarks, Etc.,l ELECTRICAL.INSPECTOR RECORD I Rev. 08-07-2015 Date: knder's Address: