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ELECTRICAL.INSPECTOR RECOR D <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcreby atnrm undcr pcnalty of Frjury thar I um cxcmpr fmm thc Contraclos' Liccnsc lrw fo] thc following rcasn (SN.70-11.5 <br />Busincss arx.l Profcssion Codc): Any City or County which rcquircs a lErmil Io q)nslrucl. allcr. improvc. dcmolish or rcpoir any <br />structurc. prior to its issuarce. also rcquircs lhc applicant lor such [rc]mil lo filc a signcd st.tcrcnl that hc or shc is liccnsd pursusnl <br />to thc prcvisions of thc Conlractor's Liccnscd hw (Chapler 9. Commncing wilh Scction 7fiD of Division 3 of lhe Busincss and <br />Ptr)fcssions Codc) or thrt hc or shc is cxcmpt thmfrom and thc basis for lhc allcgcd cxcmplion. Any violation of SNtion 703 | .5 hy any <br />upplicant for a pcrmil subjecls lhe applicanl lo a civil pcnalty of not morc lhal fivc hund]ed dollars ($sfi)). <br />_l.as ownerofthepropcrty.ortnyempbyceswithwagcsaslheirsoleconrpensalion.willdotheworkandthcstructurcisnol <br />intcrxled or otfered for sale (Sc.,c.7044. Busincss and Profcssiorrs Codc: Thc Contractor's Liccnsc [;tw docs not apply to an owncr of <br />thc proJ:crry who builds or improvcs thcreon. ard who docs such work hintsclf or hcrself or through his or hcr own crnployccs. <br />proviclcd that such inrproverncnts arc not intendc(l orofl'crcd for sah. lf. hou'cver. thc huildirrg or improvemenl is sold within one ycar <br />of corrrphtion. thc Owner Buildcr will have thc burdcn of proving that hc or she did not build or inprove thc propcrly for thc purynsc of <br />salc). <br />_1. as owncr o[the propcrly. anr cxclusivcly contracting with liccnscclcontraclors lo conslruct thc 704.4. Busincss <br />and I'nltbssion Codc: 'fhc Contraclor's Liccnsc Law docs not apply lo an owtrer proJrcrty who thcrcon. <br />and who conlracts ftlr such projects with a C<lnlractor(s) liccnsed pursuant <br />_l arn exempt under lirr this <br />t)ate: (d'- 1 ^rl <br />I hcrcby alllrrn undcr pcrralty ol'pcrjury onc <ll'lhc followirrg <br />-l <br />haveandwill rnaintainaCcrtit'icateofConsenttoSclf'-lnsurcforworkcrs'contpcnsation.as providcdlbrbyScction3Tfi)ofthc <br />Latxrr Code. for the lrcrformance of thc work l'or which the pcrnrit is issucd. <br />_lhavcandwill nraintainworkcrs'cotnpcnsationinsurarrce.as requirctl byScction3Tfi)ofthcLahorCodc,forlhcpcrfortnanceof <br />lhc work ftrr which this pcrmit is issued. My workcrs' conlpcnsalion insurancc carricr and Jxrlicy numbcr are: <br />Policy Numbcr: Expires: <br />_l certify that ilt the pcrfirrrruncc <lf thc work ftrr which this pcrrrrit is issued. I shall nol ernploy any person in any tnanner <br />so as to hccornc suhjcct to the workcrs'conrgrcnsation laws of California. and agrcc lhat if I should bccotnc subject to tlre <br />rvorkcrs' conrpcnsation provisions oI Scction .17(X) ol'thc l,ahrr Codc. I shull. lirrthu'ith cotnply with thosc <br />WARNING: Failurc lo sccurc workcrs' cotnpcnsitlitlt arrd slrall nnd <br />civil fincs up to ()nc hundrcd lhousan<l dollars arldition ot'for thc <br />.Scction 3O7(r of thc l.alxrr Codc. intercst attd attorrcy's <br />l)ate: 3-1 -\1 <br />I hcrcby alfirnr undcr pcnalty of perjury that I am liccnscd under provision of Chaptcr 9 (comnrcncing with <br />o[ thc Busincss arrd Prol'essions Code. and rny liccnsc is in full lbrcc and ell'cct. <br />7(D{)t ol'Division J <br />Liccnse Class: License Numbcr: <br />l)ale:('onl r:rclor <br />W <br />I hcrcby aflirm undcr Fmlty ofFrjury thal lherc is a construction lcnding agency for thc pcrfonnancc ofthc work for which this Frnit is <br />issucd (Sm. 3097. Civ. C.). <br />kndcr's Nam: <br />Lrnrlcr's Adtlrcss: <br />APPI ICANT DECLARATI()N <br />I hcrcby affinn under penalty of pcrjury one of thc following dcclarttions: <br />Denrolition Permits-Asbcstos Notification Fedcral Regulations (Titlc 40. Part6) <br />-Rcquircd <br />Letter ol' Notification <br />_l ccrtily that thc fcdcral rcgulalions rcgnrtling usbcslos rcrrxrval arc not this projccl. <br />I agrcc lo corttply wilh all City lntl (irunty_l ccrtify lhal I have'rcad this thlt lhc <br />ordirranccs antl .Statc Laws rclating ol'this City and C-'ounty to cntcr uJxrn lhc <br />atxrvc n**ntioncd propcrty lirr <br />A;lplic:url or Agertl Sign:rlure : <br />huikling <br />Itt.rrrrilrt. nanre ( ;lrinl ): <br />iorr. and <br />irrlirrrnat ion <br />i, 6--7-11l)ntc: : <br />Site-Work <br />Underground <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Buildinq <br />Under Slab / Floor <br />Bonding I Grounding / UFER <br />Transformers <br />Torqueing <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Wails (Roush) <br />Ceilings (Hard & Soffit Rouqh <br />Ceilinqs (T-Bar Rouqh) <br />Nleter Release <br />r/.-) <br />Rouqh II]'ruv )lalhu 7d 6o <br />Service l\Ieter tl .A <br />FINAL /"/d{/20 VMX <br />Notes, Remarks, Etc I <br />n(} rl? ,