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APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION I hereby affirrn under penalty of perjury that I am exempt from the Contractors' License Law for the following reason (Sec.7031.5 Business and Profession Ctxle): Any City or County which requires a grrmit to construct, alter, improve. tlermlish or repair any structure, prior to its issuance. also requires the applicant for such permit to file a signed statenEnt that hc or she is licensed pursuant to the provisions of the Contractor's Licensed Law (Chapter 9. Commencing with Section 7000 of Division 3 of thc Business antl Professions Code) or that hc 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 more than five hundred dollars ($500). _1. as owner of the property. or my employees with wages as their vlh compensation, willdo the work and the stnrture is not intended or offered for sah (.Sec.7044. Business and Professions Code: The Contractor's License Law does not apply to an owner of the property wlxl builtls or impnrves thercoru arxl whr does zuch wrrrk himself or herself or through his or hcr own employees. provided that such improvernents are not intended rlr offerctl for sale. I[ hrwever, the buikling or inprovenrnt is sokl within one ]â‚¬ar of complerion, the Owner Buikler will have the burden of proving tlut he or she did not buiH or impruve the property for the purpose of sale). -1, asownerof theproperty. amexclusivelycontracting with licensetl contractorstoconstruct the project (Sec.7044, Business arxl hoftssirn Code: The Contractor's License Law does not apply to an owner of proSrerty who builds or improves thereon. and who contracts for such pnrjects with a Contracto(s) licenserl pursuant to the Contraclor's License Law). -l am exempt under Section-, B. & P.C. for this reason. WORKERS' COMTDENSATION Dl.'CLARA'flON I hereby affirm under penalty of prjury one of the folklwing declarations: _l have and will maintain a Certificate of Consent to Self-lnsure frrr workers' compensation, as provided for by Section 3Tfi) of the LaborCode. for the performance of the work for which the permit is issued. LPk antt witt maintain workers'compensation insurance, as required by the work for which this permit is issued. My wurkers' compensation insurance Section 3700 of the [:bor Code, for ttre perftrrmance rrf CAand prlry number are: T PIF,.Qo.oF Policy > _l certify that in thc performance of the work for which this permit is issued, I shall not empkry any person in any manner so as to beconr subject to thâ‚¬ workers' compensation laws of California, and agree that if I should becorne suhict to the workers' compensation provisions of Section 3700 of the Labor Ccxle, I shall, forthwith comply with thosc provisions.. WARNING: Failure to secure workers' crrmpensation coverage is unlawful. and shall subject an employer to critninal penalties antl of compensation, damages as provided for the 4/Zlc2Sa 9 (commencing with Section 7m0) of Division 3 of the Business and hofessions Code, and my license is in full force iuxl effect. License c q foe ?-c u s CONSTRUCTION LI.'NDING AGENCY I hereby affirm under pnalty of prjury that there is a construction lending ageocy for the lrcrformance of the work for whkh this grermit is issued (Sec. 3097, Civ. C.). Lender's Name: lrnder's Address: APPLICANT DECLARATTON I hereby affirm under penalty of perjury one of the following declarations: Demolition Permits-Asbestos Notification Federal Regulations (Title 40, Part6) -Required Letter of Notifrcation I certifv that the &"n,ty,r*, t trru" federalregulations rcgarding asbestos renxrvalare not applicable to thls projecr. I agree to conrply with all City and Countyread this application antl the ahlve inflrlrnration ordinances and .State Laws rclating to ahrve rnentioned property for inspection Applicant or Agent l'ermitee name > of this City and enter Site-Work Underqround Pole Bases Liqht Standards Spas, Pool, Fountains Siqns (monument) Life Safety /Low Voltaqe Fire Alarm I Dampers Communications Cable Buildinq Under SIab I Floor Bonding I Grounding I UFER Transformers Torqueinq Sub-Panels Air Conditioners Roof Top Equipment Factorv Wired Unit Walls (Conduit) Walls (Rouqh) Ceilinos (Hard & Soffit Rouoh I I lt t Ceilings (T-Bar Roush)7lu/?/K Meter Release / Rouqh Service N/eter t/,i / FINAL lq2n/d-1 w614.{4,V6 Notes, Remarks, Etc.J I ELECTRICAL.I NSPECTO R RECO RD t Rev. 08-07-2015