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ELECTR!CAL.! NSPECTOR RECORD t\Q n-, ?n,t f,, APPROVALS DATE ID/SIG COMMENTS OWNERBUILDERDELCARATION I I hoeby affirrn und6 penalty of psjury that I m excmpl from the Conlractos' Licre Law forlhe following r@n (Sft.7031.5 Busincs arxl Profsion Code): Any City or County which require a lmnit to comtrud. alt6. improvc. donolish or rcpair my struclue. fior to its isuilce, also rcquirB the applicant for such pcmit to filc a signcd sldmBt that hc or shc b liccnscd psuut to the provisioE of thc Contractor's Licosed kw (Chaptq 9. Cornmcncing \r'ith SBtion ?000 of Division J of thc Busine md Prcfssions Code) or that he or she is cxmpt thrcfrom ild the b6sis for the allegcd exemption. Any violation of Scction 7031.5 by any applicant for a pf,nit subjets the applicant to I civil pcnahy oftrot more the five hundrcd dotl&s ($500). _1. as owner of the property. or my employees with rvages as their sole compensation. willdo the work and the structure is not intendecl or offered for sale (Sec.7044. Business and hofessions Code: The Contraclor's License larv does not apply to an ou.ner of the property u'ho builds or improvâ‚¬s thereon. and who does such rvork himself or herself or through his or her orvn employees. provided that such irnprovonents are not intended or offered for sale. If. however. the building or improvernent is sold within one year of completion. the Orvner Builder will have the burden of proving tha he or she did not build or improve the propoty for thc purpse of sale). -1. as owncr of the property. am exclusively contracting with licensed contractors to construct the projett (Sec. 7044, Business and Profcssion Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon. and who contracts for such projects with a Contracto(s) licensed pursuant to the Contractor's License Law). -l arn exempt under Section-. B. & P.C. for this reason. Date: Owner:_ WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the follorving declarations: -l havc and will maintain a Cerrificate of Consent to Self-lnsure for workers' compensation. as provided for by Section 3700 of the Labor Code, for the performance of the rvork for rvhich the permit is issued. f,t nru. and will maintain workers' compensation insurance. as required by Section 3700 of the Labor Code. for the pcrformance of the work for which this permit is issued. My workers' compcnsation insurance carier and policy number are: ,u,,,).'Ef.-rrohfratv Policy *r,r*, -Expirel: I _l cerrify that in the performance of the rvork for w'hich this permit is issued. I shall not ernploy any person in any manner so as to become subject to the workers' compensation laws of California. and agree that if I should become subject to the rvorkers' compensation provisions of Section -3700 of the Labor Code. I shall. forthrvith comply with those provisions..I WARNING: Failure to secure workers'compensation coverage is unlarvful. and shall subject an onployer to criminal peraltr$ and civil fines up to one hundred thousand dollars ($100.000). in to the cost of compensation. damages as provided for lthe Section of Labor Code. interest and fees. I hereby affrrm under penalty of perjury that I am licensod under p,rovision of Chapter 9 (commencing with Section 7000) of Division -1 of the Business and Profcssions Code. and my licersc is in full force and effect. c ruoColqSg License Date: _License t1 CONSTRUCTION LENDING AGENCY I hoeby allirm undr pcralty of pcrjury that thqc is a construaion bnding agmcy for thc pcfomt of thc rcrk for which this pqmit b isucd (Se. 3097, Civ. C.). l-ender's Name: Lender's Address: APPLICANT DECLARAI'ION I ha'eby aflinn under penalty of perjury one of the following declarations: Dernolition Perrnits-Asbestos Notification Federal Regulations ('title 40. Part6) -Rcquirld lâ‚¬tta of Notification -l cGtify that thc fcdsal rcgulatiom njuding rbctos rmoval rc not applicable to this prcjc1. -l cqlify that I hryc @d this applicalion and statc thd thc abovc infomation is conEt. I agr to @mply with all City ud County ordirecâ‚¬ &d Statc hB rclalhg to buildirg codrucrion. rd hqâ‚¬by 8uthoriz rcprGatrative of this City ud Couty to atq upon thc above rnentioned property for D.,.i il lq lrfApplicant or Agent Permitee name (print): Site-Work Underground Pole Bases Light Standards Spas, Pool, Fountains Siqns (monument) Life Safety /Low Voltage Fire Alarm I Dampers Communications Cable Buildins Under SIab / Floor Bonding I Grounding / UFER Transformers Torqueing Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rough) Ceilings (Hard & Soffit Rough Ceilings (T-Bar Roush) Meter Release Rough lq--lq -l q e+8 Service Meter / -lo'? FINAL t?. - t1-t"r/ Notes, Remarks, Etc.