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APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcrcby aflirm undcr pcnalty of perjury that I m cxcmpt ftom thc ContrrctoB' Liccn* ljw for thc followitrg rcasn (Se.7011,5 Business and Profcssion Code): Any City or County which rcquircs a prmit to onslruct, altcr, improvc, dcmtish or rcp.ar 8ny slucturc, prbr to its issuancc, also rcquircs thc spplicant for such pemit to frlc a signed statcmnt ihst he or slrc k liensd pusant to thc prcvisions of the Conbrctor's Liccnscd lrw (Chapter 9, Comcrcing with Scction 7000 of Division 3 of thc Busircss {d Professions Code) or that hc or she is cxcmpt thsefrom and thc b&sis for thc allcgcd cxcmplion. Any violation of Setk n 703 1.5 by atry applicani for a pcmil subjsts the applicant to I civil pcmlty of not mrc than fivc hundrcd dolles ($5m). _1. as owner of thc prof,crty. or my cmployccs with wagcs as thcir solc compcnsation. will do thc work and thc structurc is not intended or offered for salc (Sec.7M4, Business and Professions Code: The Contractor's Licensc l-aw does not apply to an owner of the propcrty who builds or improvcs thcreon, and who docs such work hirnsclf or hcrself or through his or hcr own employees, provided that such improvenrcnts are not intcndcd or offcrcd for sah. If. howcvcr, thc building or improventnt is soH within one )rcar of conphtion. thc Owncr Builder will havc thc burden of proving that hc or she did not build or improve thc propeny for thc purynsc of sh). -1, as owner of the propcrty. am cxclusively contracting with liccnscd contraclors lo construct thc projcct (Sec. 7W, Business and Profcssbn Code: Thc Contractor's License Law does not apply lo an owner of propcrty who builds or improves thereon, and who contracts for such proprts with a Contracto(s) licenscd pursuanl lo thc Contraclor's Licensc [aw). -lamexemptunderSection-'B.&P.C.forthisreason. I)ate: WOITKERS' COM PENSA TION DT'CI ARATION I hcrcby affirm undcr pcnalty of pcrjury onc of thc following dcclarations: -l have and will maintain a Certificate of Consent to Self-lnsurc for workcrs' compcnsation, as provided for by Section 3700 of the I-abor Code, for the pcrfornrance of thc work for which the pcrmit Ls lssued. _l have and will maintain workers' compensation insurancc. as rcquired by Section 3700 of thc l-abor Codc, for thc pcrformancc of the work for which this pcrmit is issued. My workcrs' compensation insurance carrbr and policy number are:\ arrlvTâ‚¬ fl)uD ltpt*?- oF Lk Policy Ll I -l ccrtify that in thc pcrfornunce of thc work for which this pcrmit is issucd. I shall not cmploy any [rcrson in any manncr so as lo bccomc subjcct to the workcrs'compcnsalion laws of California. and agrce that if I should bccomc subict to the workers' compcnsation provisions of Section 3700 of the l-abor Codc. I shall. forthwith comply with thosc provisions. . . WARNING: Failure to sccurc workcrs' conrJrcnsation covcrage is unlawful. and shall subjcct an cmployer tgcriminal pcnaltics and civil fincs up lo onc hundrcd thousand dollars ($100.000). in addition to thc cost of compcnsation. damagi.s as providcd for thc Scction 3076 of thc l,abor Codc, intcrcst and altorncy's ?7 I hercby affirm undcr pcnalty of pcrjury that I arn liccnscd Chaptcr 9 (comrrrcncing with Scction 70OO) of Division 3 of the Business and Professions Code. and my liccnsc is in full forcc and cffcct. Liccnsc Nurnbcr: 'gfral 463co L W I hercby afnrm undcr pcnalty of Jrcrjury that thw i6 8 @nstruction bnding agcrcy for thc perfomncc of thc work for which lhis pcmil is issued (Scc. 3(x)7, Civ. C.). [4ndcr's Namc: lrndcr's Address: APPLICANT DE'CI ARATION I trreby affrrm under pcnalty of pcrjury one of thc following declaralions: Demolition Permits-Asbestos Notification Fcdcral Regulations (Titlc 40, Part6) _Required l,ctter of Notifrcation _l ccrtify that thc fcdcral rcgulations rcgarding asbcstos rcnrovalarc not applicablc to this projcct. L_l certify that I havc read this application arul state that thc above information ordinances and Statc [:ws rclating to building construction. and hereby authclrizc is corrcct. I agrcc to comply rcprescntatrrqs of this City with all City and County and County to cnter ulnn thc above rncntioncd property for Applicant or Agent \ Permitee name Site-Work Underqround Pole Bases Liqht Standards Spas, Pool, Fountains Siqns (monument) Life Safety /Low Voltage Fire Alarm / Dampers Communications Cable Buildinq Under Slab / Floor Bondinq I Groundino I UFER Transformers Torqueincr Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit)tl Walls (Rouqh)Kll'(l?(VKVVl Ceilinqs (Hard & Soffit Rouqh lt I Ceilinss (T-Bar Rouqh) N/eter Release Rough Service N/eter lr A FINAL l0l'7Al?\D$kvw Notes, Remarks, Etc \ ELECTRICAL.INSPECTOR RECORD Dr.rr nO n7 On{ tr Owner:- -Expires: t l*t--