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ELECTRICAL,INSPECTOR RECORD APPROVALS DATE !D/SIG COMMENTS OWNER BUILDER DELCARATION I hseby affrm undo pmalty of pcrjury that I m cxcmpt film thc Contractos' Licosc tiw for the follorving rcen (Se.70-1 1., Buinos od Profcssion Codc): Any City or Coutrty which requirs a pmnit to coNtruct, altc. improvc, dmolish or r.pair uy structue. prior to its issumcc, also require thc applicilt for such pennit to 6lc a signcd statmmt thal hc or sht{icosed puruut to thc t ovisioc of thc Contractor's Licensed law (Chaptq 9. Commacing with Sction 7000 of Division 3 of thc Busins ud Prcfsions Codc) or that he or she is crcmpt thqefrom ed thc basis for the alleged ermpbn. Any violation of Sction 7031.5 by any applicant for a pemit subjets lhe applicant lo a civil penahy of not more thu lirc hun&cd dollds ($500). _1. as owner of the property. or my employees with wages as their sole compensation. lvilldo the rvork and the structure is not intended clr offered for sale (Sec.7M4. Business and hofessions Code: I'he Contractor's License Law does not eply to an owner of the properry who builds or ilnproves thereon. and who does such work hirnself or herself or through his or her ou.n employees. provided that such irnp,rovanents are not intended or offered for sale. lf. horvwer. the building or improvement is sold within one year of complaion. the Or,rrner Builder will have the burden of proving thd he or she did not build or improve the propoty for the purpose of sale). __1. asorvneroflheproperly. amexclusivelycontracting rvith licensed contraclorslo construct theproject (Sec.7044. Business and hofession Code: 'l'he Contractor's License Law does not apply to an orvner of property rvho builds or improves thereon. and rvho contracls flor such projects rvith a Contractor(s) licensed pursuant to the Contractor's License Law). -IamexemptunderSection-.B.&P.C.forthisreason.l)alc }VORKERS' COI}TPENSATION DECLARATION I hereby alTirm under penalty otperjury one of the follorving declarations: -l have and will maintain a Certificate of Consent to Self-lnsure for rvorkers' compersation. as providcd for by Section -1700 of the Labor Code. for the performance of the rvork for which the permit is issued. _l have and rvill mainlain rvorkers' compensation insurance. as required by Sec'tion 1700 of the Labor Code. for the perfonnance of the rvork for rvhich this pennit is issued. My rvorkers' compensation insurance carrier and policy number are: Carrier:- I'ttlic) Ntunlrcl:lixpires: DQcefiify that irr the perforrnance of the rvork for rvhich this permit is issuecl. t shall not ernploy any person in any manner so :ls to become subject to the workers' compensation laws of California. and agrc'e that if I should becotne subject to the workers' compensation provisions of Section -j700 of the Labor Code. I shall. fcrrthrvith cornply with those provisions.. I WARNING: Failure to secure workers' compensation coverage is unlaw'ful. and shall subject an anployer to criminal penalties and civil fines up to one hundred thousand dollars ($100.000). in addition to the cost of compcnsation. damages as provided for the Section -3076 l.atxrr and attorney's fees. ,( Lt('ENSLI) ('ON t'R,t("1 OR DE('LAII,\'I'ION I hereby affrnn under pcnalty of perjury that I am licensed under provision of Chaptcr 9 (comrnencing u'ith Section 7000) of Division .1 of the Business and Professions Code. and my license is in full force and effect. License Class: ^ Dere: I / f c?{I i^o-"-Nurnber:/oi6g+ o4contrector, h- L 7 /r?.n 7,f .+/feqt rct W I hreby allirm undo pcnalty of pcrjury that th6e is a construction lending agmcy for thc po'fomucc of thc work for which this pqtnil b issued (Se. -!097, Civ. C.). Lender's Narne: Lender's Address: _ APPLICANT DECLARATION I hereb), aflirm under penalty of pcrjury one of the following declarations: Dernolition Permits-Asbestos Notification Federal Regulations (Title 40. Part6) -Required Letter of Notilication -l cqtiry that the ,idqal regulalions rclading rebetos rmoval ae not applicable to lhis prcjâ‚¬1. 0! "^irv rna,tl havc rad this application dd state th8t the abovc infomation is coret. I agrc to comply wirh all city and County ordinancB trd Statc lrws rclaing to building comtruc{ion, and hmby authorirc rcprMtaliv6 of this City od County to ot6 upon thc abovc mentioned properly for inspection purposes. Applicant rlr Agcnl Signnlrrre: I'cnnilec trame (prirrl ):2f/â‚¬ /C( C./X) Site-Work Underground Pole Bases Light Standards Spas, Pool, Fountains Siqns (monument) Life Safety /Low Voltage Fire Alarm lDampers Communications Cable Buildins Under SIab / Floor Bonding / Groundang / UFER Transformers Torqueing Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rough) Ceilings (Hard & Soffit Rough Ceilinss (T-Bar Rouqh) Meter Release Rough Service Meter I t\n r\ fi-t FINAL il ?b ul INIW v(ry Notes, Remarks, Etc.I na n'7 1^4 ,ll)^