20173767 - Permit - Laserfiche WebLink

Home Browse Search

ELECTRICAL.INSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcrcby stfirm under lEnrlty of perjury that I m excmpt frcm thc Contrrclo6' Licens hw for the following rcasn (Scc.7031.5 Busincss and Profcssion Codc): Any City or County whhh rcluircs a lrrmit to @nsiruct. ilts, imprcrc, dcmlish or rcJEir ily srructrc. prior to its issuare, llso rcquircs thc applicant for such lErmit to filc a signcd stalcmnt that lE or slE is licensd pusuut to rhc prcvisions of thc Contractor's Liccnrcd las (Chaptcr 9. Comrcing wilh Sction 7000 of Division 3 of thc Busircss ud ProfcssionsCodc)orrhrthcorshciscxemptthmfrcmandthcbasirforthcallcgcdcxcrlption. AnyviolrtionofsetionT03l,5byany' applicant for a permil subjels thc spplicanl lo I civil pcnslty of not mrc lhil livc hundrcd dolles ($500). _1, as owncr of the propcrty, or my enrployccs with wagcs as thcir solc compcnsation, will do lhc work and thc structure is not intcndcd or offered for salc (Scr.7044, Busincss and Professions Code: The Contraclor's Licensc law docs not apply lo an owner of thc proprty who br,rilds or improvcs thcrcon. and who docs such work himself or hersclf or through his or her own cmployees, providcd lhat such improvcrrcnts arc mt intcndcd or offcrcd for salc. If, howcvcr, thc building or irnprovcnrcnt is sold within onc )tar of comphtion, the Owncr Buildcr will have thc burden of proving thal hc or she diri not build or improve the propctty for thc purposc of salc). _1. as owncr of thc propcrty. am cxclusively contracting with liccnscd contractors lo construct thc projcct (Sec. 7W, Busincss and Profcssion Code: Thc Contractor's Liccnsc Law does not apply to an owncr of property who builds or improves lhcrcon. and who contracts for such projccts with a Contractor(s) liccnsed pursuant to thc Contractor's Liccnsc taw). _l am lirr this I hcrcby affirm under pnalty of perjury one of thc following -l havc and will maintuin a Ccrtificatc of Conscnt to Self-lnsurc for workcrs'compcnsation, as providcd for by Section 3700 of thc labor Codc. for the pcrformancc of thc work lbr which thc pcrrnit is issued. _l havc and will maintain workcrs' comlrcnsation insurancc, as rcquircd by Scction 3700 of thc l--abor Code, for thc pcrformance of thc work for which this pcrmit is issucd. My workers' compcnsation insurancc carricr and policy numbcr arc: Policy Numbcr: Expires: -l certify that in thc pcrformancc of thc work for which this prmit is issued, I shall not cmploy any [rcrson in any manncr so as to beconrc subjcct to thc workcrs' comlrcnsation laws of California, and agrcc that if I should bccome subjcct lo thc workers' compcnsation provisions of Scction 3700 of the Labor Code, I shall, forthwith comply with those provisions.. WARNING: Failurc to liccurc workers' compcnsation covcrugc is unlawful. and shall an cmploycr to crinrinal pcnaltics and onc hundrcd thousand dollars ($ I in addition to thc as providcd for thc Latxlr Codc. intcrcst and ITT'CI ARATION I hcrcby aflirm under pcnalty of pcrjury that I am licensed undcr provision of Chaptcr 9 (commcncing with Sc"ction 7000) of Division 3 of thc Business and Profcssions Codc, and rny license is in full force and effect. , Liccnsc Class: Licensc Number: Conlractor: W I hcrcby affirm undcr lrcmlty of pcrjury that thcrc is a @nstruction lcnding agcrcy for thc perfomncc of the work for which this Frmit is issucd (Se. 3097, Civ. C.). lrnder's Name: lrnder's Address: APPLICANT NECLARATION I trrcby aftirm undcr pcnalty of pcrjury onc of thc following dcclarations: Dcmolition Permits-Asbcstos Notification Fcdcral Rcgulations (Title 40. Part6) _Rcquircd l.cttcr of Notification -l certity that the fcdcralregulations rcgarding ashstos rcmovalare not applicablc to this projcct. _l ccrtily that I havc rcad this application and statc that thc information ls corrcct. I ordinanccs and State [:ws rclating to abovc nrcntioncd propcrty for Applicant or Agent IDernritee name hcrcby ,Z/lhc Site-Work Underground Pole Bases Light Standards Spas, Pool, Fountains Siqns (monument) Life Safety /Low Voltage Fire Alarm / Dampers Communications Cable Buildinq Under Slab / Floor Bondino lGroundinq I UFER Transformers Torqueinq Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rouqh) Ceilinqs (Hard & Soffit Rouoh Ceilings (T-Bar Roush) N/eter Release Rouoh Service N/eter ., FINAL Ir ) /tq/zt Lu> 5q Notes, Remarks, Etc. fJrrr no n7 ont tr \