TEMPORARY GENERATORCity of Eas..ale
Or
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r,iCa;tvsKu CD1v rxAC rt3ec's ULCLAKATIUN I non.by attlnn that I am licensed under provisions of Chapter 9 (commencing witm section
r06'u) orvivision s of me lousiness anti rroressions Lone, ana my ticen u :v m runlo.re ana otitrot.
License Class ' Lic o- 2222
_ _ Late:IDL
Conu actor Si tta.ure:
OWNER-BUILDER DECLATION I hereby affirm that I am exempt from the Contracwr's License Law for the louowing reason (see. Mi 1-3,
tsusiness anti rrotess:ons C.otle: T c:ty or cow...ty, ,niers req»i.-av z r :t to u-MIMut, ..lto., r...g,mvc, deR1o17Sh or repair any siruccuae, prior to its
issuance, also requires the applicant for such permit to file a signe® statement that he or At is ricensetl pursuant to me provisions oime s::®.-.tracto. °s
L.Ceaa c.W_ (Cnz for Y(c®..W.onc:.� hri suctiM. -M0o) at w:i at the Business and Professions Code) or that he or she is exempt weretrom
anu the Basis for ute alleged exemption. tizzy violationoi secdon 10.3 e.3 Dy any applicant ror a permit sza;avm trio a ,rlic-:a to w ei-e1 ptzalty of not
more than five hundred dollars (WO),):
® 1, as ®:...o.- ®I mr p-„erty, a. j, a ..grloTaa.- w .tli waaSvv .- tne.:.-1c co.,pu5sat' W., -"IL dv the work, and the structure is not intended or offered,,or
sale (3ec. rM;;, Dusiness and rrofessions Coue: l at Contractor's License Law woes not apply to an owner or property -no =:Ia.. a.....r.v. m tfiuruoz;
wid nn., doom siacn .rK n.a..solf or herself or throush his or her own employees, provided that such improvementa are not inwnuetl or otlereti lot sate.
1r, nowever, [tie 6uiring or improvement is soli ; lml . 0a.e Tear 01 completi-R, m- e..... ;-t)r.laa.- Rill n..-,e trio by:do,-, of Froxia.r, that he or she did
not build or improve for the purpose of sale).
v 1, .,.a vwTr ®l fir p.uperty, v.,t c..oll:s,.oly tv..traetrs.y, with lives®.cd contractors to construca the project (Sec. 7044, Business and rtofessions Cotie-
Ine %ontrataor°s License Law aloes not apply to an owner or property who ouhus or improves tie..,, . M.a --ne comr--t3 toe mon pe®jputs with a
contractors) licenses pursuant to the Com, aA wr's License Law.).
Ie 1..W e..Wmrt I:..ac. 5R a & r-C. to. tfiff rc® t,z
,ante: owner's signature
w0K&ExY COmr"sA11un LLC 'viUm I fivn;oy amtsn audvi i..-aulty ®t pvrjwiy vne of the tolluwins declarations:
a 1 1111ve anti will maintain a certiticale Or consent to seta-insure Ior wor ' compensation, as pro,-.tion Io.- oT so®ti®R sl00 eI tno Lanor Coat, t®. the
performance of the work for which this permit is issued. g�
F.a ....a w:li ....-..tarn wo.ma v' ®-rat3a :tay.e ae.aui G, wa TI,;a1-:� Dy N-etim .3700 vt & Labor Code, Ior the performance of the work for which
this permit is issue-u. My womers' compensation insurance carrier anti policy numoer arc:
Carrier tt7 g 1'V--c ?J )V> Z74D Policy No. !J . J o !rn,
( I ni.. veet.®..:.®m -Let Do cu._s.letoa .I two l v.... .7 roti o.-.0 n= area tion=., (3 tu—u) v. lorry.
❑ l certify tnal in [ue p rmance of me wort for wnicE this permit is issueti, 1 SIMLL not employ any person in an7 manner so as io Decomv :;alijeo[ t®
the d.orKcrs' compuris®ation lana of Califomiu, and ag.Gc th®t of 1 sh®uld 5ecome subject to the workers' compensation provisions of Section 3700 of
the -aBor Coae, 1 srlall70nnwhR comply with mole provisions.
,.ace Applicant-s signature
WARNING: FAIL UM TO SECURE wORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER
I V MurVurvew rMMAL I lr.S, AF9L1 C1 V rE rinr.a ur l7J GNP. ntjimwrczv I HOUZAIN ). L)ULL A” (I liJU U00), IN AVIX I ION 10 1 HE CON t
OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SEC. 3706 OF THE LABOR CODE, 1 n.c3 1; M rt s A vl<tvr; x'3 rr r,3.
C®1v YRUC�1IU1V LENDING AGE14 :Y I h® .,by ata..:., .a..der roma tl ,at tae. ju.y tE t tha ro.s.. construction lend' agency for the performance
of ine worK for wnicR mis permit is issueti (sec. iv:r 1, Civic C.).
Lender's Name Lender's m"00ress
ArrLICAN Y'a NiGnATUKE l vvrtity that I nw% 760 th.0 wpi,lIvatior. it State that tna aba-% mf°ormation is correct, I Erre w comply with all city
anti county oralnances anti state Rws reacting to aui,tling construction, mu- nereGy authorize representatives or the City ox nasty& to entw is az m_
above-me tion roN h.—Fection p. poses. r i
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*ff&ure-5fXppdcant tUontractor or vwnery rrint Lame vats