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ELECTRICAL.I NSPECTOR R ECORD D^,, nA n-7 1n.t G, APPROVALS DATE ID/SIG.COMMENTS Site-Work Un nd Pole Bases Standards Fountains monument Life /Low Fire AIarm lDam Com munications Cable Buildi Under Slab /Floor I Ground IUFERBond Transformers Sub-Panels Air Conditioners ntuRoof Facto Wired Unit Walls Conduit Walls h rd & Soffit RoCeil h Ceil -Bar Meter Release h ?-{ Service Meter F!NAL Rema ho'eby Bt[t.t)[.R affirnr under penalty of perjury that aJn exempt frorn the Contractors'License Law for the following (Sec.70-3 .5BusinessandProfessionCode): reason Any City or County rr'hich requires permit to conslrucl.alter.improve.demolish or repair anystructure.prior to its issuance.also requires the applicant for such pennit lo file signed statetnent that he she is licensedtotheprovisionsofthe or pusuant Contractor's Licensed l.arv (Chapter 9.Commencing s'ith Section 7000 of Division of the Business andPmfessionsCode)or that he or she ts exempt therefrom and the basis for the alleged exonption.Any violation of Section 703 .5 byapplicantforpermitsubjectstheapplicanttttcivilpenalty of not any more than five hundred dollars ($500). 5!'' as owner of th9 property. or my ernployees with wages as their sole compensation. rvilldo the rvork and the structue is notintended or oflered for sale (Sec.7044. Business and hofessions Code: The Contractor's License Law does not apply to an owner ofthe propaty who btrilds or improvcs thcron, and who does such work himself or herself or through his or her own employees.provided that such improvanents are not intended or offered for sale. If. howwer. the building o, irprouement is sold within one )â‚¬arof cornpletion, the owner Builder will havc thc burden of proving that he or she did not build or imp,rove the propo.ty for the purpose ofsale). -1. as owner of the propâ‚¬rty. atn exclusively contracting with licensed contractors to consrruct the project (Sec. 7044, Businessand hofession Code: The Contractor's License Law doL nor apply to an owner of property who builds or improves thereon.and *'ho contracts for such p,rojects with a Contracto(s; licensei pursuant ro the Contraitor's License Law). _l am exempt under Section_ . B. & p.C. for rhis reason. urr", [\.o8.lfl onn"r, 6WoRKERS'Collm Iherebyaffirmunderpenalryofperjuryoneofthe,o,,o,",n*Dffiq -l have and will maintain a Ce-rrilicate of Consent to Self-lnsure for workers' compensation, as provided for by Section 3700 of rheLabor code. for the performance of the work for which thc pennit is issued. --l have and will maintain workers' compensation insurance. as required by Section 3700 of the Labor Code, for the performance ofthe work for which this permit is issuerJ. My workers' compensation insuranie carrier and policy number are: Policy Number:__Expires: (t t cerriry tul inthe pcrfomc of thc work for which this pcrmit is issucd, I shall not mploy uy pe*on in my muna$ I to bccome subjet to Ihc work6'smpcnsrt-ion- lam of califomia. ud agrc that if I shouu uccomc suulcr to'trrwork6'compcr$tionprcvisiocofs(tion3T00ofrhcLaborCodclslull.ionhwithcorpry*irfrtrro*p,oi,i"ioro-- r WARNING: Failuc to sre mrk*l TTp"tYlon covmgc is unlawful. md shall subjet u mplolc ro qiminal pqultics mdcivil fines up to onc hundrcd thoMd dollffi ($100.000). ii addition ro thc cost of compcwrion, dr*go * povidcd for thcSetion 3076 of the Labor Codc. intrGt ed dtonrcy's fc. orr., [L. Ok. \1 I hereby affirnr under penalty of pcrjury that t am licensed of the Business and Professions Cocle, and my ticense is provision of chaptcr 9 (cornmencing with Section 7000) of Division 3 in full force and effect. License Drle:_ Class: License Number: _ ('onlrnctor: _ !nw.bv.arrq1q<lcpenaltyofpcrjurythat,*ffifomanccofthcwrkforwhichthispqmitb issucd (Se. 3097. Civ. C.). Lender's Name: _ Lender's Address: _ APPLICANT DECLARATION I herelry affirm under penalty of perjury one of the following declarations: Demolition Permils-Asbestos Notification Federat Regulations (Title 40, part6) -Required Letter of Notification -l certi& that the federal regulations regarding asbcstos removal are not applicable to this projcct. (lr cerri& rhat I have read this application and state that the above information is correct. I agroe to complyordinances and State Laws rclating to building construction. and hereby authorize represextatives of this Cityabove mentioned property for inspection purpos6. with all City and County and County to enter upon the Applicnnt or Agent Signature:_ Permitee nnme (print): 3B â‚¬- ASur ru \t' o t- 11 .1