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ELECTRICAL.I NSPECTOR RECORD ().r,nQ n7 ')n,t fi APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hoeby aflirm undr pcnslty of perjury that I m cxmpt from the Contmcton' Licffc tiw for thc followiag rcen (Sfi.7031.5 Busin6s and Prof6sion Codc): Any City or County rvhich requira a pemit to comtruct. altc. inprova dernolish or rcpair my structue. prior to its isuuce. also require the applicilt for such pemit lo filc I signcd stahmt thal he or shc is licosd puEuut to thc provisiore of thc Contractor's Licâ‚¬nscd lzw (Chapt6 9. Commmcing with Seclion 7000 of Division 3 of thc Busine md Prcfesions Code) or that hc or she is eempt thqcfrom ud the bssis for the allcged exmption. Any violation of Ssiion 70-f 1.5 by any applicant for a pdmit subjBts thc applicant to a civil pcnalty of not morc thm livc huodrcd dollus ($500). _1. as owner of the property. or my employees with wages as their sole compensation. rvilldo the w'ork and the structure is not intenderJ or offered for sale (Sec.7M4. Business and Professions Code: The Conlractor's License Larv does not apply to an owner of the property rvho builds or improves thereon. and rvho does such $'o* himself or herself or through his or her orvn employees. provided that such irnprovonents are not intended or offâ‚¬red for sale. If, horvever. the building or improvement is sold within one year of cornplaion. the Orvner Builder s'ill have the burden of proving that he or she did not build or improve the propory for the pu4nse of sale). ___1, as owner of the propeny. am exclusively contracling rvith licensed contraclors to construct the project (Sec. 7044. Business and hoftssion Code: The Contractor's License Larv does not apply to an ou'ner of property u,ho builds or improves thereon. and rvho contracts for such projects rvith a Contracto(s) licensed pursuant to the Contractor's License Larv). I arn exemot under Section _. U. & P.C. for this reason. l)nte:Orr rrcr: WO RKER,S' COM PENSATION DECT.ARATION I hereby affrrm under penalty of pcrjury one of the following declarations: _l havc and will maintain a Ccrtificate of Consent to Self-lnsure for workers' comSrcnsaion, as provided for by Section 3700 of the Labor Code. for the poformance of the work for which the permit is issued. _l have 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' compensation insurance carrier and policy numb are: c^**, S*c.k Fctu/ poricyNr^b*, q23Ll 3L/3 Expires: O^ S/t-tlt- -l certi& that in the pcrformance of the work for which this pomit is issued. I shall not employ any person in any manner 5 so ns to become subject to the workers' compensation taws of California. and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code I shall. forthwith comply with those provisions.. WARNING: Failure to secure s,orkers' compensation coverage is unlarvful. and shall subject an onployer to crirninal penalties and civil fines up to one hundred thousand dollars ($100.000). in addition to the of cornpensation, damages as provided for the Section 3076 of the Labor Code. interest and attorney's fees. o*e: ll- lb-l-,>tl DECI..ARATTON I hereby affrnn under penalty of perjury that I am liccnsod under provision of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Profcssions Code, and my liceirse is in full force and effect. License cr*, 6 _License ll-tL\-L>tl Contractor, (1 (]ONS'I'RU("I'ION LI'NI)IN(; ACI'N('\' I heeby affim unda pei, alty of pqjury that th6c is a comtruction lqrding agacy for thc pofomuce of the work for *'hich this Fmh b issued (Sec. 3097, Civ. C.). tendcr's Name: APPLICANT DECLARATION I heneb), aflirm under penalty of perjury one of the following declarations: Demolition Permits-Asbcstos Notification Federal Rcgulations (Title 40, Part6) -Required Latcr of Notification -l certi$, that the federal regulations regarding asbestos removal are not applicablc to this project. _ ,I certify that I have read this application and state that u'ith all City and County and County to enter upon theordinances and State Laws relating to building above mentioned property for inspection Applicrnt or Agent Signature:-6 l)ale: //-1J'*o!? IDernritee name (prirrt): E t 9a loc L Site-Work Underground Pole Bases Lisht Standards Spas, Pool, Fountains Siqns (monument) Life Safety /Low Voltage Fire Alarm lDampers Communications Cable Buildins Under Slab / Floor Bondinq I Groundinq / UFER Transformers Torqueing Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rough) Ceilinqs (Hard & Soffit Rouqh Ceilings (T-Bar Roush) Meter Release Rough Service Meter I / FINAL / L/Zo/7 / oLl Notes, Remarkb, Etc.I /// /-/l/-/ /Cad Lc'2^l^ Lender's Address:t