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ELECTRICAL.I NSPECTOR RECORD APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DEI,CARATION .I hqeby 8[fum undq peralty of pcjury thar I m crempt from the Contracto6' Licmc lzw for the following r@n (Se.7031.J Busins and Profsion Codc): Any City or County which rcquirs a pomit to co$truct. altc, improvq dcmolish or rcpair ay structue prior to its issuuce, also requirc the applicet for such pennit to lile a signcd statmqt that hc or shc is licced pN6t to the provisioE of thc Contractor's Liccnsed Law (Chapter 9. Comercing with Setiotr 7000 of Division f of thc B6in* md Profcssions Code) or that he or she is exempt thccfrom ild thc basis for thc allcgcd exeinption. Any violation ofs(tion 703 1.5 by any applicsntforapennitsubjetsthe applicmttoacivilpenaltyofnotmorethafivehundrcddollm($500). _1. as owner ofthe propcrly, or my etnployees with wages as their sole compensation, willdo the work and the structure is not intcnded or offered for sale (Sec.7044, Business and Professions Code: The Contractor's License law does not apply to an owner of thc property who builds or improvcs theron, and who docs such work himself or hersclf or through his or her own employees. provided that such improvonents are not intcndod or ofFcrod for sale. I[, howwer, the building or improverncnt is sold within onc ]er of cornplaion" the Orrner Builder will have the hrden of proving that he or she did not build or improve the propoty for thc purposeof sale). -1, as owner of the property, am exclusively contracting with liccnsed contractoni to construct the project (Sec. 7M4, Buiness and Prcfession Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such pirojccts with a Contracto(s) licersed pursuant to the Contractor's License l-aw). -l am exempt under Section-. B. & P.C. for this reason. I hereby affirrn under penalty of perjury one of the following _l have and will maintain a Certifrcate of Consent to SelFlnsure for workers' compensation. as provided for by Serction 3700 of the L-abor Code, for the pcrformancc of the work for which the pennit is issued. _l have and will maintain workers' compensation insurance, as required by Section 3700 of the L:bor Codc, for the pcrformance of the work for which this pennit is issuod. My rvorkers' compensation insurancc carrier and policy number are: Policv Number: Exoires: _l certi& that in the pcrfornrance of the work for which this pennit is issued, I shall not ernploy any person in any rnanner so as to bocome subject to the workers'compensation laws of California, and agree that if I should become subject to the rvorkers' compensation provisions of Section 3700 of the tabor Code, I shall. forrhwith comply with those provisions.. WARNING: Failure to secure workers' compensation coverage is unlawful. and shall subject an anployer to criminal penalties and civil fines up to one hundred thousand dollars ($100.000). in addition to the cost of compensation, danages as provided for the Section -3076 of the Labor Code, interest and attorney's fees. I hereby affrm under pcralty of pcrjury 3 of the Business and Profcssions Code. and my license is in full force and effect. License Class: License Number: CONSTRUCTION LENDINC AGENCY I hcby affim unda pqulty of pcrjury tha th@ is I onstruction knding agocy for thc pqfotruce of thc wrt for uhich this pqmil b isucd (Sc. 3097, Civ. C.). Isrdq's Nmq Lender's Address: APPLICANT DECLARATION I hocby alfinn under penalty of perjury one of the following declarations: Dcrnolition Permits-Asbestos Notilication Federal Regulations (Title 40, Part6) _Required Later of Notifrcation -l cdiry that thc fcdoal rcgulatiom rcgarding sbctos rmoval rc not eplieblc to this pmjâ‚¬l. -l cqtiry that I have r@d this spplicatiotr atrd statâ‚¬ that thc abovc infomdion is coret. I sgrc to @mply with all City and Couty ordimc6 ud Statc lrw rclating to building oNrrudioa ad hqcby authorirc rs?rMtstiv6 of this City md Comty to 6tE upon thc abovc mationcd prcpcny for impction pupos App[st or Ag6t Sigmturc: Drlc:_ Pernrite+ nrme (print):____ Site-Work Underqround Pole Bases Light Standards Spas, Pool, Fountains Siqns (monument) Life Safety /Low Voltage Fire Alarm I Dampers Communications Cable Buildins Under Slab / Floor Bondinq I Groundinq / UFER Transformers Torqueing Sub-Panels Air Conditioners I I ) Roof Top Eq uipme nt l}jlvrv l0 r2lol Wfu (fi Factory Wired Unit Walls (Conduit) Walls (Rouqh) Ceilinqs (Hard & Soffit Rouqh Ceilings (T-Bar Roush) Meter Release I I I ./) Rough IU I l?,1il Dfh)n t%6 Service Meter , FINAL Notes, Remarks, Etc. Dnrr nA n7 nn4a Carrier: l)rl o'Contrnctor:_