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ELECTRICAL.I NSPECTOR RECORD APPROVALS DATE ID/SIG COMMENTS OWNER BUTLDER DELCARATION I heeby affrrm undr penalty of perjury that I m exempt from the Contracton' Licw law for the following remn (Sff.7031.5 Buinos and Prcfsion Code): Any City or County which requile a pornit to @Ntruct, aho, imprcvq donolish or rcpair uy struc{rc, prior to its isumce, alrc require the applimt for such pqrnit to filc a signed statmmt that he or slrc is licdrcd pffiuilt to thc prcvisiom of thc Contrrctor's Licrued Law (Chapta 9, Commmcing wilh Strtion 7000 of Division 3 of the Buins ad PrcfesionsCode)orthathâ‚¬orshe isexemptthqefromadthe brcisforthe allegedexmption. AnyviolationofSeaionT03l.5byuy applicmtforapermitsubjststhâ‚¬ applicmttoacivilpenaltyofnotmorethufivehundreddollm($500). -[, as owner of the property, or my employees with wages as their sole compensation, will do the rvork and the structure is not intended or oflered for sale (Sec.7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of the property who builds or improves thereon. and who does such wort himself or herself or through his or her own employees, provided that such improvonents are not intended or offered for sale. I[, however. the building or funprovement is sold within one year of complction, the Owner Builder will have the burden of proving that he or she did not build or improve the property for the purposeof sale). -1, as owner of the propâ‚¬rty, arn exclusively contracting with licensed contractorc to construct the project (Sec. 7M4, Business ard hpfession Code: The Contraclor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a Contracto(s) licensed pursuant to the Contractor's License Law). -l arn exempt under Section-, B. & P.C. for this reason. l)qt o. WORKERS' COMPENSATION DECLARATTON I hereby affrrm under penalty of perjury one of the following declarations: -l have and will maintain a Certificate of Consent to Self-lnsure for workers' cornpensationr as provided for by Section 3700 of the Labor Code. for the performance of the work for which the pennit is issued. -l have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the perfonnance of the work for which this permit is issued. Jrrly workers' compensation insurance carrier and policy number are: Sr.^r..c F-^J PolicyNu.u"r, 9Lltot6 - Z.rt\ Expires:j-L'L -l câ‚¬diry that in the performance of the work for which this pâ‚¬mit is issued, I shall not mploy any pcrmn in ay maner rc rtobwomcsubjettothcworto'@mpmaionlawsofCalifomia"mdagethatiflshouldb@omcsubj@ttothe r workes' ompmation prcvisiom of Scrion 3700 of the labor Code, I stull, fonhwith omply with thos prcvbiom.. WARNING: Failure to sue workem' compwtion covuage is unlawful. ud shall lubj@t a mploy6 to sfuninal ponltie md civil fines up to one hundrci thousmd dollm ($100,000), in addition to the cost of compcmation, &maga r providcd for thc Section 3076 of the Labor Code, interest and attorney's nate: ?-u-?-t DECLARATION I hereby affrm under penalty of perjury that I arn licensed under provision of Chapter 9 (cornmencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Q-(rc Number:?gf oiy D,.rc: 1'L?-Ll e-/ CONSTRUCTTON LENDING AGENCY I hftby affm undq pernlty of pojury that thse is a @Btruction lmding agqcy for the paforrmce of the work for which this pqmit b issued (Se. 3097, Civ. C.). Lender's Name: l,endcr's Addrcss: APPLICANT DECLARATION I hereb),afiinnunder penalty of perjury one of the following declarations: Dernolition Permits-Asbestos Notification Federal Regulations (Title 40, Part6) -Required Letter of Notification I I ceniff that the federal regulations regarding asbestos removal are not applicable to this project. -t cdiry that t have md this application md state tha the abovc infomation is cofiecl. I agre to comply with all City and County ordinancB md State Laws rclating to building corotruction, ud hscby authorirc repr*ntativB of this City ed County to cnt6 upon thc above rnentioned property for Applicant or Agent Permitee -L'. LI Site-Work Underground Pole Bases Lisht Standards Spas, Pool, Fountains Signs (monument) Life Safety /Low Voltaqe Fire Alarm I Dampers Communications Cable Building Under Slab / Floor t A l u{-,, Bonding I Grounding / UFER Y\ \or L \ L>I.I ,q I -ol Transformers I Torqueinct I t A ,1 Sub-Panels ->rr Air Conditioners I Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Roush) Ceilings (Hard & Soffit Rough Ceilinqs (T-Bar Rouqh) l/eter Release Rouqh Service ltleter I r I C,,/, FINAL (-vD / Notes, Remarks, Etc. Dnrr nA n7 On{ tr '7\\X V \ Dt{4t //' VV