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ELECTRICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNI'R BUILDI'R DI'I,CARATION <br />I hereby affrnr under penalty of perjury that I arn exempt from the Contractors' License l-aw for the following reason (Scc.7031.5 <br />llusincss and Protbssion Codc): Any City or County which requircs a pcrmit to construct, altcr, improvc, dcmolish or rcpair any <br />structurc, prior to its issuance. also rcquires tlle applicant for such penuit to filc a sigrrcd slaternent that lp or she is licerrsed pursuant <br />to thc pmvisions of thc Contraclor's l,icenscd law (Chapter 9. Commencing with Scction 7000 of Division 3 of the Busincss and <br />Professions Code) or that lrc or she is exempt therefrom and tlre basis for tlre alleged exenrption. Any violation of Section 7031.5 by any <br />appticant for a pennit subjects the applicant to o civilpenaltyof not rnorc than five hundred dollars ($500). <br />_1. as owncr ol'the propcrty. or my clnployecs with wagcs as thcir solc compcnsation, willdo thc wnrk and the stnrcturc is not <br />intcrxled or offeretl for sale (Sec.7M4, Busincss and Professions Cotle: Thc Contractor's Liccnsc [-aw does not aPPly to an owncr of <br />the pmperty wlro builds or inrproves thereon, and wlxr does srch work himself or lrerself or ttuough his or her own employees, <br />provided that such improvcmcnts arc not intended or offcrcd for sale. Il. howcver, trc building or funprovcnrcnt is sold within one )aar <br />of completion, tlre Owncr Buil&r will have thc burden of proving thd hc or she tlid mt buill or inpmve tlrc propaty for thc purposc of <br />llale). <br />_1. as owner of the propcrly, am exclusively contracting with liccnscd conlractoni to conslrucl thc projcct (Sec. 7(Xa, Business <br />and hrolbssi.m Code: The Contractor's License Law does not apply to an owner of proSrcrty who builds or improves thereon. <br />and who contracts for such pro_iects with a Contractor(s) liccnscd pursuant to thc Conuactor's Liccnse Law). <br />B. & P.C. <br />I hercby affirnr unclcr pcnalty of pcrjury onc of tlte tbllowing <br />_l have and will nuintah a Certil-rcate of Consent to Self-lnsure for workers' contpensation, as pnrvided for by Scction 3700 of the <br />labor Code, for the ;rcrforrnance of thc work for which thc Srcrrnit is issucd. <br />_l lrave arrd will nuintain workers' conrpensation insurarrce. as required by Section 3700 of the Labor Code, for the perfonrunce of <br />the work for which this pcrmit is issucd. My workers' compcnsation insurance carricr and gxrlicy number are: <br />Policy Number: Expires: <br />_l ccrrify that in tlrc lxrfornrancc of thc work for which this pcrmit is issucd, I shall not cmploy any person in any m:rnner <br />so as to becorne subjcct to thc workers' compensation laws of California. and agree that if I slnuld bccorrc subject to the <br />workers' conpensation provisions of Section 3700 of the Labor C'ode, I slrall, forthwith conrply with those provisions.. <br />WARNING: Failure to secure workers' compensation coverugc is unlawful, and shall subjcct an employcr to criminal penahics and <br />civil fines up to one hundred tlnrusand dollars ($100.000). in addition to tlrc cost of comSrctsalion. danrages as provided for the <br />.Section 3076 Codc, intercst and lecs. <br />0 4 <br />DI'CI,ARATTON <br />I hereby affirm under pnalty of pcrjury that I anr licenscd untler provision of Chapter 9 (conurrcncing with Sccrion 7000) of Division 3 <br />of the Business and Professions Codc. arxl my licensc is in full forcc and effect. <br />Licensc Class: Licensc Number: <br />CONSTRUCTION LENDING AGENCY <br />I hcrcby aflirm undcr pcnalty of pcrjury that thcrc is a construction lending agency for the pcrformance of thc work ltrr which this permit is <br />issued (Sec. 3097. Civ. C.). <br />Lender's Nanre: <br />APPLICANT DECLARATTON <br />I ffiy affrmunder penalty of pcrjury one of the following declarations: <br />Denrclition Pcrmits-Asbcstos Notification Fedcral Rcgulations (Title 40. Part6) <br />_Rcquircd l-etter of Notification <br />_l certily thal the fcdcral regulations regarding &sbestos removal arc nol applicable to this project. <br />_l certify that I luve rcad this application and state tlut thc above infornration is correct. I agrec to conrply with all City and County <br />ordinances and State Laws rclating to building constructiorl and hereby authorize representatives of this City and County to entc{ upon the <br />above rnentioned property for <br />Alllllicant or r\gent <br />Pcrnritcc nanlc <br />purposes.r dl>n\zo <br />Date:- <br />Site-Work <br />Underqround <br />Pole Bases <br />Lisht Standards <br />Spas, Poo!, Fountains <br />Siqns (monument) <br />Life Safety /Low Voltaqe <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under SIab / Floor I I 1l <br />Bonding I Groundinq / UFER /a2v/b OZ"r'H ,ff <br />Transformers / <br />Torqueinq <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factorv Wired Unit <br />Walls (Conduit) <br />Walls (Roush) <br />Ceilinqs (Hard & Soffit Rouoh <br />Ceilinqs (T-Bar Rouqh)I / <br />N/eter Release ttlzta 0lktM,K <br />Rough <br />Service Meter I .t I ,l/ <br />FINAL '//rtl'-v Vf-/rvr7v - v ce <br />Notes, Remarks, Etc. <br />Rev. 08-07-201 5