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ELECTRICAL-I NSPECTOR RECORD APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DEI,CARATION I hoeby aflim undo poalty of pojury that I m erempt from lhe ContractoB' Licose Law for the following reMn (58.70-11.5 Businas md Profssion Code): Any City or County which require a perrnit lo construct. alts, improve. dmolish or repair any struclure, Irior lo its isuance. also rcquirs the applicml for such pmnit to file a signed statmmt lhat he or she is licmsed pureuanl to the provisions oflhe ('ontractor's l-icensed Larv (Chapto 9. Commencing lvith Sfflion 7000 of Division 3 ofthe Busincss md ProfessionsCode)orthalheorsheiscxcmptthoefromddthebasisfortheallegedexemption. AnyviolationofSetionT03l.5byany applicant for a pmnit subisls thc applicant to a civil penalty ofnot more than five hun&cd dollars ($500). _ l. 6 o\\'ns of the proFE ty. or my employec rvith rvage ro their $le compmsalion. will do the work md the slnrctue is not intoded oroffscd for Mle (Se.7M4. Busins ad Profssions Code: 'fhe Conlraclor's l-icose Larv doe not apply to an oNns of lhe propoty rvho builds or improve thtron. ild who do6 such work himself or hmelf or through his or her ou'n employcs. provided that such imlrovqnmls ac dol intdded or offtrcd for sle- If. horvevq. the building or irnJnovonmt is rld within one y6 ofcotnplelion. the (Ivnq Buildo rvill have the burdo ofproling thal he or she did nol build or irnprote the prcpaty for lhe pupoFof ule). _ I, o owno of the propsty. m cxclusively contraoing with licmed conlracloB lo coNlruct the prcjsl (S(. 7044. B6ins md ProfessionCode:'lheContractor'sLiccnscLawdo6nolapplyloeownsofpropertywhobuildsorirnprovesthereon. md who contracts for such projats wilh a Contrado(s) licmsed pursuanl to the Conlractor's LiceNe Larv). I m exempt unds s(tiof,--. B. & P.c. for this r6on. l)nlc:owner, - UOSX&BS:CAMIENSAI!9N - DECLARATION I hoeby affirm under penalty of pojury one of thc following dalaatiom: _l have od will maintain a Cenificatc of Commt to Self-lnsure for *'ork6'comp€Mtion. o provided for by Sstion .1700 of thc Labor Codc. for the pofomilce of the work for which the pennit b i$ucd. I havc and will maintain workm' cornpemation insurance. 6 required by Setion 3700 of the Llbor Code. for the pcrfomancc of the rvork for rvhich lhis pmit is issued. My rvorkm'insurance canier md policy numba a'c: ( Policy Nunrbcr:Irxpiresl -l certify that in the perforrnance oflhe work for lhis plmit is issued. I shall not mploy any perrcn in any mmno o s kr become subjet to thc workqs' cornposalion laws of Califomia. and agre lhal if I should become subj(l to the u'orkss' cornpensation provisions ofSation 1700 ofthe l-abor ('ode. I shall. fonhrtith cornply rvilh thos provisiofls.. WARNINC: Failure lo recure workers'compmsation covtrage is unlawful. md shall subjet m mployo lo Fiminal penaltiB and civil lincs up lo one hundrcd lhousand dollars in addition lo thc cost of compenutiou. danags o provided for the Seclion 1076 oflhr t-alnr Codc. intcrst and fes. o","' *l-3 -lC I hqeby amrtn undr p6ahy ofpdjury that I m undcr provision ofChapts g (commencing with Setien 7000) ofDivision -l of lhe Busincs and Profesions Code. md my license is in full force md effect 8)6 tL'r D,te, I-\LO I heeby aflirm undo poalty ofpdjury that lhse is a coEtruction lending issucd (Se. 3097, Cir. C.). L€ndq's Nme: for lhe pq fomance of the work for which this pmnit is Lenclq s Addres; APPLICANT DECLARATION I hoeby affm unds penalty ofperjury onc of the following declaations: Demoliton Pqmits-Asbstos Notification Fedsal Regulations (Title 40. Part6) -Required Letls of Notificatioo _l c6tiry lhat the Hqal rcgulatioN regdding obctos ronoval are not applicablc to this prcjat. Il certify ttrat I havc read this application md state that the above infomalion is corect. I ag.e lo comply with all City and County ordinancs dd State Laws relating lo building coNtrucliof,. md hqcby authorizc retr6mtativ6 of this City md Couoty to otq upoo the abovc mcnlioncd propeiy ft)r Applicatrt or Agcrt Permite nnme (print): purposcs. Site-Work Underqround Pole Bases Light Standards Spas, Pool, Fountains Signs (monument) Life Safety /Low Voltage Fire Alarm / Dampers Communications Cable Building Under Slab / Floor Bondinq / Groundinq / UFER Transformers Torqueing Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rouqh) Ceilinqs (Hard & Soffit Rouqh Ceilings (T-Bar Rough) Meter Release Rough Service Meter F!NAL 4lc{eo q Mt 2D) Notes, Remarks, Etc.ur r-i.m"ctc, ^ 4-0ID Drte: a a