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Owner-Buildct Dt.ldltion <br />I hcreby affim undcr pcnalry ofpcrjury that I am excmpt fom thc Contracto6' Licens: Low for lhc following rcoon Scc.703 L5 Busincss <br />ud Profession Codc): Any Cily or County which rcquirs a pcmit to construcl, alter, improvc, dcmolish or repair uy structurc, prior to ils <br />issuancc. also rcquirc thc applictrt for such pcmit to lilc a signcd stalcmcnl that he or shc is licoscd puGuut to thc provisions oflhc <br />Contractor's Liccnscd Law (Chaptcr 9, Commcncing with Scction 7000 of Division 3 ofthc Busincss ud Profcssions Codc) or thal hc or <br />shc is cxcmpt thercfrom and rhc buis for the ollcgcd cxcmption .Any violotion of Scction 701 1.5 by any applicu( for a pcmit subjecb the <br />a civil pcnalty of not morc thil fivc hundrcd dollm ($500) <br />s owncrof lhe propcrly, or my employccs with wages u their sole comPcnsation, <br />( Sec 7044, Busincss md Profcssions Codc: Thc Contractor's Lic6s. <br />will do the work md thc structurc is not intended <br />or offcrcd for salc Law des not apply to u owncr ofthc propcny <br />who builds or improrcs thcrcon. md who dcs such work himselfor herelfor through his or her own cmployccs, providcd that such <br />improvements arc not intcnded or offcrcd for sale. lF, howcver, thc building or idprovement is sold within one ycu of completion, thc <br />Owner-Buildcr will have thc burdcn of proving that he or shc not build or improvc for thc purpose of sale). <br />_1, s owncr of thc propcny, m cxclusively contracting with liccnscd contractor to construct thc prcject ( Scc 7044. Busin6s ild <br />Profession Codc: The Contractor's Liccnse Law dcs not apply to m owncr ofpropcrty who builds or impnovcs thcreon , md who <br />contracts for such projecb with a Contractor(s) liccnscd puEuilt to lhc Contraclor's Liccnse Law.) <br />m cxempl under section &PC forthisrecon <br />Date /r,^ /r*a fli,u,--To <br />t',' <br />WORKERS COIlIPENSATION DT]CLARATION <br />I hereby affim under pcnalty ofpcrjury onc ofthc following declarctions <br />_l have ud will maintain a Cenificatc of Consent to Self-lnsurc for workcn' compensalion. 6 provided for by Secrion 1700 of lhc <br />Labor Code, for thc pcrfomance of thc work for which the pmit is issucd <br />_l haveandwill mainrains,okcrs'compensationinsurmce.s rcquiredbyScction3T00ofthet-aborCodc.frrrthepcrfomanccofthe <br />work for which this pemit is issucd My workers' compensation insurance canier and policy nunrbcr rre' <br />Can'icr <br />(Tf on nccd not bc complelcd if thc pennit is for Onc hundrcd dollm l$ l00l or lcss) <br />{l ccnify rhat in rhe pofommcc of thc work for which this pemit is issucd, I shall not cmploy any ptrson in any manncr so N to <br />bccmc subjcct to thc workcm ' compcnsation laws of Califmiq md agrcc that if I should bffomc subjcct to thc workcm' <br />md civil <br />fincs up to onc thousand doll$s ($100,(X)0).in addition to the cosl ofcorrpensation. damagcs u providcd for thc Section -1076 of <br />thc Labor Code, intcr.sl Md otromcy's fccs <br />I,ICINSED CONTRACTORS DECI,ARATION <br />I hcrcby affim under penalty of perjury that I am licenscd under provision oi Chapter 9 (commencing with Section 7000) of Division 3 of <br />thc Rusinms Md Professions Codc. rnd my liccnsc is in full forcc ud effect <br />Policy Numbcr:---E*Pi.cs, <br />Liccnsc Cl6s:_ Liccnsc Number <br />Datc, _Contmctor; <br />CONSTRTICTION I,ENDING AGENCY <br />I hereby aflimr undcr pcnalty of pcrjury that thdc is a construction lcnding agcncy for thc pcrfommce of the work for which this pcmit is <br />issucd (Sec 3097, Civ C ) <br />l-cndcr's Nanrc <br />Lcnder's Addrcss <br />APPI,ICANT'S T'ECI,ARATION <br />Demolition Pemits-Asbcstos Notillcntion Fcderal Regulations (Titlc 40. Pm 6) <br />_ Required Lcttcr ofNotificalion <br />I cenify that thc fedcril regululions regarding obestos removal are not applicable m this project <br />_ I cenify rhat I havc rcad rhis application md state that thc above infomation is corect I agree to comply with all City and Counly <br />ordinrnces and State Laws reloting to buildinS construction. and hereby authorize representatives of this City rnd County to entcr upon the <br />abovc mcntioncd propmy for inspcction <br />or agent sig <br />Pemittee nme (\,> <br />_Datc <br />DATE ID/SIG.COMMENTSAPPROVALS <br />Site-Work <br />Underground <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Signs (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor <br />Bonding / Grounding / UFER <br />Transformers <br />Torquing <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rough) <br />Ceilings (Hard & Soffit Rough <br />Ceilings (T-Bar Rough) <br />Meter Release <br />I <br />(6>r 'ucta <br />Rough <br />Service Meter <br />6-Z-a p.crs za3FINAL <br />Notes, Remarks, Etc. <br />) <br />ELECTRICAL.INSPECTOR RECORD <br />o, <br />r/rf/ol <br />l I