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APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hocby aflirm undcr pef,slty of pojury that I m cxcmpt ftom thc Contraclon' Licre Larv for thc following rwn (Se.7031.5 Businas ud Profosion Code): Any City or County which rcquire a pcrnil to eNtrucl. alte. imprcvc dmolish or repair a:y structuc pior to its issumce. also rcquirc thc applicmt for such pcflnit to file I signcd statmot that he or shc b liccnscd pEuut to thc provisioN of thc Contractor's Licenscd Law (Chapts 9. Commmcing with S6tion 7000 of Division 3 of thc Buins md Prcfc$ions Codc) or that hc or shc is cxempt thqefiom md thc basis for thc allcgcd exmption. Any violatiotr of Scction 7031.5 by any applicant for a pmit subjets thc applicant lo 8 civil pmalty of not morc thil five hundrcd dollus ($500). -_1. as owner of the property. or my ernployees with wages as their sole compensation. rvilldo the rvork and the struclure is not intended or offered for sale (Sec.7044. Business and hofessions Code: The Contractor's License Law does not apply to an owner of the properly who builds or itnproves thermn. and rvho does such \r'ork himself or herself or through his or her own employees. provtdd that such improvonents are not intended or offered for sale. lf. horvet/er. the building or improvement is sold rvilhin one )â‚¬tr of complaion. the Orvner Builder will have the burden of proving tha he or she did not hrild or improve the propoty for the purposc of sale). _1. as o\.\,ner of the Fnoperty. am exclusively contracting with licensed contracloni to construct the project (Sec. 704t1. Business and hofâ‚¬ssion Code: The Contractor's License Law does not apply to an ou'ner of property rvho builds or improves thereon. and u'ho contracts for such projects rvith a Contracto(s) licensed pursuant to the Contractor's License taw). _l am exempt for this\ I hereby affirm under penalty of pcrjury one of the follon'ing declarations: _l have and will maintain a Certiflrcate of Consent to Self-lnsure for rvorkers' compensation. as provided for by Section 3700 of the Labor Code, for the performance of the work for which the pa'rnit is issued. _l have and rvill maintain rvorkers' compensation insurance. as required by Section 3700 of the Labor Code. for the performance of the rvork for rvhich this permit is issued. My workcrs' compensation insurance carrier and gnlicy numkr are: Policy _Expires: _l certify that in the performance of the work for rvhich this perrnit is issued. I shall not employ any person in any manner so as to beconre subject to the rvorkers' compensation larvs of California. and agree that if I should bccome subject to the rvorkers' comperuiation provisions of Section 3700 of the labor Code. I shall. forrhrvith cornply rvith those provisions.. WARNING: Failure to secure rvorkers'is unlarvful. and shall subject an to and thousand dollars to the cost of the and I hereby affrrm under penalty of perjury that I am licensed under provision of Chapter 9 (comrnencing with of the Business and Professions Code. and rny license is in full force and effect. 3 [.icense -License Number: Date: Contrnctor:_ W I hrcby affirm undo pcnalty of pqjury thst thsc is a connrucion landing agocy for thc psfommcc of thc work for which this pcrmil is issucd (56. 3097, Civ. C.). Lender's Name: Lender's Address: APPLICANT DECLARATTON I herelry aftinn under penalty of perjury one of the following declarations: Demolition Permits-Asbestos Notification Federal Regulations (Title 40. Pat16) _-Required Letter of Notification -l cstiry that thc fcdqal rcgulalioG rEgading rbelos rmoval uc not eplicablc to this prcj61. _l cdiry that t hflc rad this application md statc Iha thc abovc infomation b cor6t. I agreto comply with all Cityed County ordinmce md Ststc t ws rclding to building condruction, and hscby authorirc rcpreotarivs of tlis Chy od Couty to otq upon thc above rnentioned property for Applicant or Agent B.& 7000) Permitee nanre purposes. Dete:_ Site-Work Underground Pole Bases Light Standards Spas, Poo!, Fountains Signs (monument) Life Safety /Low Voltage Fire Alarm I Dampers Communications Cable Building Under Slab / Floor Bondinq I Groundinq / UFER Transformers Torqueing Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rouqh) Ceilinss (Hard & Soffit Rouqh Ceilings (T-Bar Roush) Meter Release Rough D, Service Meter It \ +ISIAL- Vrrb 0'r-7)\IqN,[,I Notes Remarks Etc. \v ELECTRICAL.I NSPECTOR RECORD ) no n7 ?n{ r Carrier:_ v