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ELECTRICAL.INSPECTOR RECORD APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION I hcrcby afltrm undcr pcmlty of pcrjury that I m excmpt ftom thc Contracton' Liccns llw for thc following rcasn (58.7031.5 Busincss and Prcfcssion Codc): Any City or County whhh rcquircs a pcrmit lo onstruct, alts, imprcrc, dcmlish or rcpair my smcrurc. lrhr lo its issuancc, als rcquircs the 8pplicant for such permit to file I signed slatemnt that hc or shc is liansd pusuet to thc prcvisions of ftc Conlractor's Licnscd Law (Chaptcr 9, Commcncing with SEtion 7000 of Division 3 of thc Busincss ild PmfcssiotrsCodc)orthatlrcorshcircxcmptthcrefrcmedthcbssisfortlrcallegcdcxcmption. AnyviolationofSationT03l.5byany spplicanl for I Jxrmil subixts the applicant to a civil pcnalty of not morc thfi fivc hundrcd dolltrs ($5OO). '' ' -1. as owncr of thc propcrty. or my cmployccs wilh wagcs as lhcir sole compcnsation. willdo the work ard thc structurc is not interdcd or offercd for sale (Scr.7044, Business and Professions Code: The Contractor's Liccnse [^aw does not apply to an owner of the pmJrcrly who builds or irnproves thcrcrln. and who dcrcs such work himsclf or hcrsclf or through hi.s or hcr own cmployccs. providcd that such improvcnrcnls arc not intcndcd or offercd lbr sah. lf. howevcr. thc building or improvcnrcnt is mld within onc year of cornplction, thc Owner Buildcr will havc thc burdcn of proving that hc or she did not build or improve the propcrty for thc purJrosc of sale). -1, as owncr of the property. am cxclusivcly contracting with liccnscd contraclors to conslruct thc project (Sec. 7W, Busincss and Profcssbn Code: The Contraclor's Licensc Law does not apply to an owner of propcrty who builds or improvcs thcreon, and who contracts for such proFcts with a Contracto(s) liccnscd pursuant to the Contractor's Licensc hw). _l anr c'xcnrpt undcr P.C.this 3O-7-"1 I hcreby afllrm under pcnalty of pcrjury onc of the following declarations: -l havc and will maintain a Ccrtilicate of Consent to Sclf-lnsurc for workers' compensation. as provided for by Section 3700 of the I-abor Codc. for thc performancc of thc work for which the grcrmit ls issued. -l havc and will maintain workcrs' compensation insurancc. as requircd by Section 3700 of thc l-abor Codc, for the grcrformance of the work for which this perrnit is issucd. My workers' comlrcnsation insurance carricr and policy number arc: Policy Numbcr: Expircs: _l ccrtily that in the pcrformancc of thc work for which this prmit is issued. I shall not cmploy any pcrson in any manncr so as to bccomc subjcct to the workers' compcnsation laws of Californr1 1n{agrag ths, if I thoyld-.bcconrc subjcct to lhc workers' compcnsation provisions of Section 3700 o$the l.abq Codc, t shafl. forthwith coniptf wlth thosc provisions.. WARNING: Failure to sccure workcrs' compcnsation coverugc is unlawful, and shall subjcct an cmploycr to criminal pcnalties and civil l-rrrcs up lo one hundred thousand dollars ($100,000). in addition to the cost of compcnsation, damagcs &s provided for the Section 3076 clf thc l-abor Codc. intcrest and atlorney's fccs.-zl I hereby affirm under pcnalty of pcrjury that I am liccnscd under provision of Chapter 9 (commcncing with Section 7000) of Division 3 of thc Busincss and Professions Codc, and my license is in full forcc and effect. Numbcr:Liccnse Class: Dete: W I hcrcby stftrrn undcr pcnalty of pcrjury thut there is a @nstructiol lcnding agency for thc pcrformnce of thc work for which this permit is issucd (Sc. 3097. Civ. C.). [.cnder's Namc: I-cndcr's Addrcss: APPLICA NT ITF'C] ARATION I hcrcby allrrm undcr penalty of perjury onc of thc following dcclarations: Derrrolition Pcrmits-Asbestos Notification Fcderal Regulations (Titlc 40, Part6) _Required lrttcr of Notification -l ccrtify that the fcdcralrcgulalions rcgarding asbcstos rcmovalarc not applicablc to this projcct. _l ccrtify lhat I havc read this application and statc that thc ahrvc information is correct. I agrc',c to comply with all City and County ordinanccs and Statc [,aws rclating to construction. and hcrcby authorize rcprcscntatives of this City and County lo cntcr upon thc abovc mcntioncd ;lropcrty for Applicant or Agenl Permitee nanre ( a,-)o-Ll Site-Work Underground Pole Bases Light Standards Spas, Pool, Fountains Signs (monument) Lite Safety /Low Voltaqe Fire Alarm / Dampers Communications Cable Building Under SIab / Floor Bondinq I Groundi ns I UFER Transformers Torqueincr Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rouqh) Ceilinss (Hard & Soffit Rouqh Ceilings (T-Bar Rough) N/eter Release Rouqh Service N/eter FINAL '8//-A LLr 9.a ter@> %;7 Notes, Remarks, Etc. On,na n7 .)n{ tr