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a ELECTRICAL-I NSPECTOR R ECORD APPROVALS DATE !D/SIG.COMMENTS OWNER BUILDER DELCARATION I hcrcby ulfrm under Fnahy of JErjury thal I m cxcmpt ftom lhc ConkacloB' Liccn$ lrw for the followinS rcasn (Ss.7031.5 Busincss and Profcssion Codc): Any Cily or County which requircs a Frmil lo onslruct, alter. improvc. dcmlish or rc;ut any structurc. prior to its issumc, also rcquircs thc applicant for such Frmit to lilc a signcd slalcmnt that hc or shc is licenscd pumuant to lhc prcvisions of the Contrsctor's Liccnscd l:w (Chaptcr 9, Commcrcing with Scclion 7000 of Division 3 of the Busincss and ProfessionsCodc)orthrlhcorshciscxemptthcrcfromandthcbasisfortheallcgcdcxemplion. AnyviolationofscrlionT03l.5byany opplicanl for a pcrmit subj&ts thc applicant to a civil pcnalty of not mrc than five hundrcd doll{s (5500). _1. as owncr of thc propcrty. or my cmployccs with wagcs as their sole compcnsation. willdo thc work and lhc stnrclurc is not intcndcd or offercd for s"rlc (Scr.7044, Busincss and hofcssions Codc: Thc Contractor's Liccnsc law does not apply lo an owncr of thc propcrty who builds or inrproves thcrcon. and who docs such work hinrself or hcrself or throuBh his or hcr own ctnployccs. provided that such improvcmcnts are not intcndcd or offcrcd for salc. lf. howcvcr. the building or improvcrncnt is sold within onc ycar of complction, the Owncr Buildcr will havc thc burden of proving thal trc or she did not build or improve lhc proFrcrty for thc purpsc of sale). _1, as owncr of thc property, am cxclusivcly contracting with liccnscd contractors to construct thc projcct (Scc. 7M4, Business and ft,olbssion Codc: Thc Contraclor's Liccnsc Law does not apply to an owncr of propcrty who builds or improvcs thereon. and who contracts for such projccts with a Contracto(s) liccnscd pursuant to thc Conlraclor's Licensc [aw). -IamcxcmptundcrScction-,B.&P.C.forthisrcason.I)ate: WORN F'IIS' COM PF'NSAT'ION DECLARATION I hereby affirmunder pcnaltyof pcrjuryonc of the following declarations: _l havc and will maintain a Certifrcate of Conscnt to Sclf-lnsure for workers' comgrcnsation, as provided for by Scction 3700 of the Labor Codc, for thc pcrformancc of the work for which thc pcrmit is issued. _l havc and will maintain workers' compcnsation insurancc, as rcquircd by Scction 3700 of thc Labor Code, for thc grcrformance of thc work for which this prmit is issucd. My workers' compcnsation insurarrce carrier and plicy number are: Co^5 Policy L (1.. _l certify that in thc performance of thc work for which this permit is issucd, I shall not cmploy any pcrson in any manner so as to bccome subjcct to thc workcrs' comJrcnsation laws of California. and agrce that if I should bccome subject to lhe workers' cornglensation provisions of Section 3700 of thc l-abor Codc. I shall. forthwith comply with thosc provisions.. WARNING: Failurc lo liccurc workcrs' compcnsation covcrage is unlawful. and shall subjcct an cnrploycr to crirrrinal pcnaltics and civil fincs up to onc hundred thousand dollars (S100.0m). in addition to thc cost of cotnlrcnsation. darnages as providcd for thc and altorncy's ,::: " 3076 0r' ?i\: ;"f i-; *' I hercby allrrnr undcr pcnalty of pcrjury that I anr liccnscd undcr 9 (conrnrcncing with Section 7000) of Division 3 of thc Busincss and Professions Code. and my liccnse is in full forcc and effcct. License Class:L-\0 Nurnbcr: o,r" 4 r0lo, I hereby alfirm undcr pcnalty of prjury thal thcre issued (Sec. 3097, Civ. C.). a construction lcnding agency for the performancc of thc work for which this pcrmit is I.cndcr's Nanrc: [.cnder's Address: APPI ICANT DECLARATION I hcreby affrm under penalty of pcrjury one of thc following declarations: Dernolition Permits-Asbestos Notification Federal Regulations (Title 40, Part6) -Rcquircd l.etter of Notifrcation -l certify that the federal rcgulations ,"gurdinl asbcstos removal are not applicable to this project. -l certify that I have read this application and state that the abovc information i, "*""r. I agreetb compty with all City and County ordinanccs and Statc laws rclating to building construction, and hcrcby rcprcsentativcs of this City and County to abovc mcntioncd propcrty for purposcs. Applicant or Agent Permitee name ( r authorizc d q uJxln thc Site-Work Underground Pole Bases Liqht Standards Spas, Pool, Fountains Siqns (monument) Life Safety /Low Voltase Fire Alarm / Dampers Communications Cable Building Under Slab / Floor ,, Bondins lGroundinq / UFER 8/z;/2,"h*ilaTransformersrlI Torqueinq Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rouqh) Ceilinqs (Hard & Soffit Rouqh Ceilinqs [-Bar Rouqh)I r N/eter Release aftsrh tut@ T I Rouqh Service N/eter /^/,) F!NAL W a>fZr A"n @ Etc. J Dnrr nO n7 On{ tr Owner:- 77n17