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ELECTRICAL-INSPECTOR RECORD <br />APPROVALS DATE !D/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcreby aflrm under pcnllty of pcrjury that I dn cxcDrpt frcnr lhc Cotrlrxclors' l-icen$c Law l'or thc folk)wing rcayr (Scc.7oJl.5 <br />Busincss and Prolcssion Codc): Any Cily or County which rcquircs n Ircrnrit k) construcl. nltcr. inrprovc. dcil()lish or repuir any <br />slruclurc. prior k) its issuance. also rcquires lhe applicant li)r such [f,rmil lo lilc a signed slaterrcnt thal he or she is liccnscd pursuanl <br />k, lhe provisions of lhe Conlracbr's Liccnscd Law (Chaplcr 9. Corrrnencing wilh SectioD 7000 ol Divisbn 3 ol thc llusincss and <br />ProfcssioilsCodc)orlhallEorshciscxcmlillhcrcfronrandlhchrsisforlhcallcgcdcxcnrpthn. AnyviolatioilofScclionT0]l.5byany <br />apflicanl for a pcrmil subjccts thc applicant to a civil penahy of not more thdn llve hundrcrl dollurs ($5(X)). <br />-1. <br />as owncr of lhc propcrly. or my enlployccs with wagcs rs thcir solc compcnsation. willdo thc work aod thc rtruclurc is txil <br />irlculcd or olfcrcd firr elc (56.7044. Busincss and Prolc\sions Codc: 'l hc Conlracklr's Liccnsc Irw docs Dot npply k) rn (,wncr of <br />lhcprcpcny whobuildsorirnprovcslhemn.andwhodoessuchworkhiorselforhcrsclforihroughhisorherownetrtployccs. <br />provided lhal such improvctrEnts irc nol iilendcd orollcrcd lor sale. li howcver. thc huilding or inprovcnunt is soki qithir inN )eu <br />o[complction. lhc Owncr Buildcr will hilvc lhc hurdcn of provi0g thrt hc or she did trot huild or inrprovc thc pm|rcrly li)r thc purF)* o[ <br />salc). <br />-1. <br />cs owncr of lhc propcny. am cxclusivcly conlracling wilh liccnscd conlrdclors lo conslrucl lhc projcct (Scc. 7()1,1. Busiilcss <br />ond Pn)ll\siil Codc: l he Conlractor's Liccnsc Law docs D(il lfply to un owtrcr o, propcny wh() huikls or inrprovcs lhcrcon. <br />and who cotrlracls for such pr(,jccls with a Corilmcbr(s) licenscd pnnuant k) lhc ConlrilckrJs Liccnsc Luw). <br />-Iamexcmptundcrsccli()l1-.B,&P.C.forlhiSreason.()wner: <br />WORKERS' C(TlltPENSAl'ION <br />DECLARATION <br />I hcreby aflrm under pcnshy ofpcrjury one ofthe Ibllowing dcclarations: <br />-l <br />have atrd will mintain a Cerlificale otConsent lo Selllnsurc lor workers' comlrensation. as providcd lbr by Scction 3700 of the <br />tibor Codc. for lhc pcrfortrEncc ofthc work lbr which thc pcrmil is issucd. <br />|E[l havc ana will rnainlain workers' compensation insurance. as rcquircd by Scction .1700 of thc tibor Code. for thc pcrlbrruncc of <br />lhc work for which this fcrrnit is issucd. My workcrs' conrpcnsaliorl iilsuruncc canicr and grlicy rrurntrcr urc: <br />coni",,9(A(l4L lN OeM rr ( r','li1 ItPolicy Nu I0oO0o z lo <br />_l cerlify Ihut iri lhc pcrlornlancc of lhc work tbr which lhis pcrmit is issucd. I shlll not cnrphy any pcNon in dny rnunncr <br />v) as b bcconE suhjel b lhc workcrs'conlpcnsalion laws ofCalili)rlia. rnd iltrcc thnt if I should hcco[r subjcct to tlrc <br />workers'coilllrcnsationprovisionsofScclion3Tfi)olthclitx)rC(xlc.lshall.foilhwithconrplywiththo{pt1)visions.. <br />WARNING: Failurc kr sccurc workers'cotrrpcnsalion covcrngc i! unlawtil. and shall suhiccl ut etnpk)ycr tr crinrinll pcnahics and <br />civil fincs up lo otrc hundrcd lhousand dollrrs (Sl00.UI)), iD addition to lhc cost ofcotrtpelsntion. rhnngcs ar proli(lcd fi)r the <br />Scclion 1076 ol thc (ixlc, irilcrcst xnd nlkrnrcy s ltcs <br />3,'2q 4 !/ /-/ <br />I hcrcby aflirnt undcr pcnalty of pcrjury lhal I am liccilscd undcr p,r)visi(n ofChuplcr 9 (cotrril1cncing with Section 7(XX)) ol l)ivision 3 <br />of the Busiucss rnd Prolessions Code. uild my liccnsc is irr lirll li)rcc rnd clltct. <br />l.iccnsc 0 c- lo Nurrra(r:lrsz 6 :t <br />I hcrcby affirrn undcr Jrcnalty of Jrcrjury th{l lhcrc is a conslruction lcndiig agcncy for thc pcrforil)ilncc oi thc work t-or which lhis JErmit is <br />issucd (Scc. 3097. Civ. C.). <br />hndcr's Nanrcr <br />kndcr's Addrcss: <br />APPLICANT DECLARATION <br />I hcrr,by allim under penalty of perjury onc of lhc folbwing dcclualions: <br />Dcmolilion Pcrmits-Asbcstos Notification Fedcral Rcgulations (Tille 40. Pan6) <br />El'(cquired t*trer <)f Noritlcarion <br />p-l ccnify rhar rhc fcdcralrcgulations rcgarding asbcslos rcmoval orc nol applicablc h this prejcct.vil <br />Ll ccnily that I havc rcad thrs applicatioo nrd slalc that thc ntnvc infornulion is corcct. I sgre b comlly wilh tll C-ity and County <br />ordinsnces and Slale Laws rclatinS lo building construclion. md hereby authorizc represeDtativcs of lhis City and Counly to entcr upon the <br />purFnscs.tln <br />Pcmlremme(p.inr. Pf/O t tv 6 <br />_ r^,", l/ul /fi <br />Site-Work <br />Underground <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safety /Low Voltaqe <br />Fire Alarm / Dampers <br />Communications Cable <br />Buildinq <br />Under Slab / Floor <br />Bonding / Grounding / UFER <br />Transformers <br />Torqueino <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouoh) <br />Ceilinqs (Hard & Soffit Rouqh <br />Ceilings (T-Bar Rouqh) <br />Meter Release <br />Rouqh <br />Service N/leterFINAL 6ffirh&* <br />Notes Rem Etc.I <br />no n7 o.\i (