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ELECTRICAL-INSPECTOR RECORD I hereby affrrm untler penalty of perjury that I am exempt from the Contractors' License Law for the following reason (Sec.7031.5 Business and Pr:fession Code): Any City or County which requires a permit to construct, alter, improve, denmlish or repair any structure. prilr to its issuance. also requires the applicant for such permit to file a signed staterEnt that hc or she is licensed pursuant to tlrc provisions of the Contractor's Licensed Law (Chapter 9. Commencing with Section 7000 of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant firr a permit subjects the applicant to a civil penalty of not rnore than five hundred dollars ($SttOl. _1, as owner of the property, or my empkryees with wages as their sole comlrcnsation. will do the work arxl the struc{ue is not intentled or offered for sale (Sec.7M4, Business and hofessions Code: The Contractor's License Law does not apply to an owner of the pruperty wtn builds or improves thererrn. arxl whl dtrcs such wrrrk himself or herself or th,rough his or her own employees, provided that such improvernents are not intendal or offered for sah. If, txlwever, the building or inTrrovenrnt is sokl wthin one )â‚¬ar of completion, the Owner Builder will have the burden of prcrving that he or shc did not buikl or improve the property for the purplse of sale). _1, asownerof the proFrcrty, amexclusivelycontracting with licensed contracto$toconstruct thc pnrject (Sec.70.14, Business and Pnrfesskrn Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such pnljects with a Conracto(s) licensetl pursuant to the Contractor's License Law). _l am exempt under Section_. B. & P.C. for this reason. Dete: WORK h' RS' COM PENSATION DECLA]IATTON I hereby affirm under penalty of perjury one of the following declarations: -l have arxl will maintain a Certifrcate of Consent to Self-lnsure for workers' compensation, as provided for by Section 37fi) of the I-abor Ccxle, for the perfonnance of the wo* for which the permit is issued. 4 have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the lrcrfrrrmance of work for which this prmit is issued. My workers' compensation insurance carrier and Jnlicy number are: I'olicy -l certify that in the performance trf the work for which this permit is issued, I shall not employ any person in any manner so as to becorne subject to the workers'compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of rhe l-:hlr Crxle. t shall, forthwith c,rmpty with tlxrsc pmvisions.. WARNING: Faiture to secure workers' compensation coverage is unlawfut, and shall suhject an emptoyer to criminal Jrenalties and civil fines up to one hundred thousand dollars ($lm.Un). in addition to the cost of compensation. damages as provided for the attrlrney's fees. I hereby affirm under penalty of perjury that I am licensed under provision of Chapter 9 (comrnenc'ing with Section 7firu) of Division 3 of the Business and Professions Code, and my license is in full firrce and effect. License CONS'I'RUCTION LENDING AGENCY .I hercby affirm under penalty of perjury that there is a construction hnrling agency for the performance of the work for which this pernut is issued (Sec. 3097, Civ. C.). Lender's Name: lrnder's Address: APIDLICANT DE,C LARATION I trreby aflrm under penalty of pcrjury one of the following declarations: Demolition Permits-Ashstos Notification Federal Regulations (Title 40, Part6) -Required Letter of Notification certify that the federal regulations regarding asbestos rennval are not applicable to this project. I have read this application and state that the above information is correct. I agree to cornply with all City and County and State Laws relating construction. and hereby authorize representatives of this City and County to enter uFxln the atxrve mentioned property for Applicant or Agent l'ermitee nanre (print): I APPROVALS DATE ID/SIG.COMMENTS Site-Work Underqround Pole Bases Liqht Standards Spas, Pool, Fountains Signs (monument) Life Safety /Low Voltage Fire Alarm / Dampers Communications Cable Building Under Slab / Floor Bondinq / Groundinq I UFER Transformers Torqueincr Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Roush) Ceilinqs (Hard & Soffit Rouoh Ceilinqs [-Bar Rouqh) Meter Release Rough Service lVleter t),A &, FINAL t FI'l,lY+{D'2 Notes, Remarks, Etc.l Rev. 08-07-2015 Section ((u t l.-l