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ELECTRICAL.! NSPECTOR RECORD .t APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hercby affrrn undr pemlty of pojury thar I m cxmpt from the ContractoB' Licw law for the following rcen (5â‚¬.703 1.5 Businss md Prof*ion Code): Any City or County which require a pennit to @struct, altq. improvq dcrnolish or rcpair uy structuq prior to its isumcc, also requirB thc applicmt for such psmit to filc a signed stamot that hc or drc b licoscd pmuut to thc provisioN of thc Contractor's Liccnscd Law (Chaptq 9. Comocing with Sction 7000 of Divisiotr 3 of the Buincs ud Prcfcsions Codc) or that hâ‚¬ or shc is cxcrtrpt th@fiom ad thc basis for the allcgcd ex@ption. Any violation of Selion 7031.5 by any applicant for a pcrmit subjats the applicant ro a civil pcmlty of not morc thil livc hundred doltus ($500). -1, as owner of the propcrty. or my cmployees with wages as their sole compensation, rvilldo the work and thc stnrcture is not intended or offered for sale (Se.7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of the property who builds or improves theron. and who does such work hirnself or herself or through his or hsr own employees, provided that such improvonents are not intended or offered for sale. I[, however. the building or improvemett is sold within one ]Ear of cornpletion, the Owner Builder will have the burden of proving that he or she did not build or improve the propoty for the purpose of sale). _1, as owner of the property, arn exclusively contracting with licensed contractom to construct the p,roject (Sec. 7M4, Business and Profession Code: The Contractor's License Law does not apply to an owner of propcrty who builds or improves thereon. and who contracts for such projects with a Contracto(s) licensed pursuant to thc Contractor's License l-aw). -l am exempt under Section-. B. & P.C. for this rcason. WORKER.S' COMPBNSATIO N DECLARATION I hereby alTirrn under penalty of perjury one of the following declarations: -l have and will maintain a Ceflifrcate of Consent to Self-lnsure for workers' compensation. as p,rovided for by Section 3700 of the Labor Code, for the performance of the work for which the permit is issucd. -l have and will maintain workers' compensation insurance, as rcquired by Section 3700 of the Labor Code, for the performance of thc work for which this pennit is issued. My workers' compensation insurance carrier and policy numbcr are: sT-|ffi Tuf{D lto /zo LtPolicy1rLn -l certi& that in the pcrformance of the work for rvhich this perrnit is issued. I shall not ernploy any person in any manner so as to becorne subjcct to the workers' cornporation laws of California, and agree that if I should become subject to the workers' conrpensation provisions of Section 3700 of the Labor 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 lines up to one hundred thousand dollars ($100.000), in addition to the cost of compensation, damages as provided for the Scction 3076 of the Labor Code, interest and attorney's feqs. l,lC IiNSITD C()N't'RAC'I'OR DECI,i\RATION I hereby aflinn under penalty of perjury that I am licensed under provision of Chapter 9 (commencing with Section 7000) of Division 3 of thc Business and Professions Code, and my license is in full force and effect. Licenseclass, CIO LicenscNumbcr:l-\LfLq I contrectory/ I -,N_r CONSTRUCTTON I F,NnrNG AGENSY there is a construction lording agency for the performance of the work for which this perrnil isI hereby affirm under penalty of perjury that issued (Sec. 3097. Civ. C.). Lcrrtlcr 's Nlrrrrc. Lender's Address: APPLICAIIT DECT {RATION I hqtby affirm undq po8lty of pojury onc of thc followiag dclaratioro: Dmolition PmitsAsbet$ Notifiqtior Fcdqal Rcgulatiore (Titlc 40, Pan6) -Rcquircd Lrttq of Notification -l catiry that thc fcdqal rcgulatioro rcgarding rbctos rmoval uc not qplicabh to this projcl. f\ ceriry tha I We md this application rd statc that thc above infomdion is orct. I agre to omply with all City ud Couty 6rdimcq ud State Laws rclating to building mNtruclion ad h@by 8uthorirc rcprMtativ6 of this City ed Couty to 6tq upotr thâ‚¬ above mentioned property for Applicant or Agent Pernritee namc 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 / Grounding / UFER /o-T-?.II-IR +z Transformers Torqueing Sub-Panels Air Conditioners Roof Top Equipment Factorv Wired Unit Walls (Conduit) Walls (Roush) Ceilings (Hard & Soffit Roush Ceilinqs (T-Bar Rouqh) l\Ieter Release lb tlo -7)0/P lt- Rouqh lb,2o-2t\3 Service Meter f D-Lo -?-t l (it'\1/ FINAL lo-Lo'Zl I \ Notes, Remarks, Etc. Drrv nO n7 nn4R \ Expires: ,,r", lo I t t I I ( o,r", ('(1, (z ( CJ