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ELECTRICAL.INSPECTOR RECORD Dr'.r nO n7 On1tr APPROVALS DATE !D/SIG.COMMENTS OWNERBUILDERDELCARATION - I, I hercby affirrn under penalty of prjury that I an cxempt frcm the Conteto6' Liccnrc [aw for thc following rcarcn (Ss.7031.5 Busincss afll Profcssion Codc): Any City or County which rcquires a ;rmil to construct. allcl improvc, dcmlish or rcJtrir aoy structurc, Irior to its issuancc, ds rcquircs lhc applicmt for $uch pcrmit to filc a sigrcd stltcmnt lhat hc or slrc is liccnrcd pumant to thc povisions of thc Contr{ctor's Liccnsd [jw (Chaptcr 9. Commncing wilh Sstion 7000 of Division 3 of thc Busincss rnd ProfessionsCodc)orthathcorshciscxcmptthrcfrommdthcbasisforthcallcgcdcxcmplion. AnyviolstionofscctionT03l.5byany applic8nt for a pcrmil subjels Ihc applicant to a civil pcnalty of not morc th.n fivc hundrcd dollars ($500). _1. as owncr of lhc propcrty. or my employecs with wagcs as thcir solc comlrcnsation. will do thc work and thc stnrtue is not intcndcd or ofl'cred for salc (Scc.7M4. Busincss and Profcssions Codc: The Contractrlr's Liccnsc Law docs not apply to an owncr of thc propcrty who builds or improvcs thcrsrn. arxl who docs such work himsclf or herself or througih his or hcr own cmployces. providcd that such improvcrncnts arc not intendcd or offcrcd for sah. If. howcvcr, thc building or improvcrrcnt is mld within one )tar of complction. the Owncr Buildcr will have tlrc burdcn of proving that hc or shc did not build or inrprove the propcrty for thc purprse of sale). -1. as owncr of the propcrty, am cxclusivcly contracting with licenscd conlraclors lo construct thc project (Scc. 7W. Busincss and [lofcssion Codc: The Contraclor's Licensc Law does not apply to an owncr of propcrty who builds or improvcs thcreon, and who conlracls for such projccts with a Contractor(s) liccnsed pursuant to thc Contractor's Liccnsc Law). -lamexcmptundcrSection-,B.&P.C.forthisrcason.Dale:--0wner:_ wortKF rts, coMPENsATroN DECLAITATION I hereby affrm undcr pcnalty of perjury one of the following dcclarations: -l havc and will maintain a Certificate of Consent to Self-lnsure for workers' compcnsation, as providcd tbr by Scction 3700 of thc Labor Codc, for the lrcrformancc of thc work for which the pcrmit is issucd. -l havc and will maintain workers' comSrcnsation insurance. as rcquircd by Scction 3700 of thc l-abor Codc. for thc Jrcrformance of the work for which this permit is issucd. My workers' compensation insurancc carricr and plicy number are: Policy Number: Expires: -l ccrtily that in thc perforrnancc of the work for which this permit is issucd. I shall not cmploy any pcrson in any manner so as to bcconre subject to the workcrs' cornpensation laws of California. and agrce that if I should becomc subject to the workcrs' compcnsation provisions of Scction 3700 of thc l-:bor Codc. I shall. forthwith comply with thosc provisions.. WARNING: Failure to sccurc workers' comF,cnsation coveragc i.s unlawful. and shall suhjcct an crnploycr to criminal pcnaltics and civil fincs up to onc hundrcd thousand dollars (S100.m0). in addition to lhc cost of comfrcnsation. darnages as providcd for the Scction 3076 of thc [:bor Codc, intcrest and attorncy's t'ccs. Date: Applicant: LICENSED CONTRACTOR DT'CLARATION I hercby affrm under penalty of pcrjury that I am liccnsod under provision of Chapter 9 (comrnencing with Section 7000) of Division 3 of the Business and Professions Code. and my liccnsc is in full forcc and effect. License Class: License Number: It..r^. W I hcrcby afftrm under pcnalty of Frjury that thcrc is a @nstructhn lcrding agcrcy for thc lErformrcc of thc wmk for which this tEmit i! issucd (Se. 3097. Civ. C.). Lcndcr's Narnc: lrnder's Addrcss: APPLICANT NECLARATION I hcreby allirrn under pcnalty of perjury onc of thc following declarations: Dcrnolition Pcrmits-Asbcstos Notification Fedcral Rcgulations (Title 40. Purr6) _Rccluircd Lrttcr of Notification -l ccrtify that thc fcdcralregulations rcgarding asbcstos renroval arc not applicablc to this project. _l ccfrify thnt I hvc rcad this application ild srotc th.t thc above infonmtion is corccl. I agrc lo comply wilh all Cityand CouDty ordinanccs ond Statc laws rclating to building construction. and hcrcby aulhorizc rcprcrcntativcs ofthis Cilyond Counlyto cnlcr ulnn thc abovc nrcnlioncd prcpcny for insfEtion purtDrcs. Applicant or Agent Dule: I'rrurilt c nltnr ( llrint): Site-Work Underqround Pole Bases Liqht Standards Spas, Pool, Fountains Siqns (monument) Life Safety /Low Voltage Fire Alarm / Dampers Communications Cable Buildinq Under SIab / Floor lt l, t A" Bondinq I Groundinq I UFER ulVlLr wa/e\0ra Transformers Torqueing Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rouqh) Ceilinss (Hard & Soffit Rouqh Ceilings (T-Bar Roush)^t I ,A N/eter Release TTbt tutfu&fi) I Rough fl A/^aService N/eter 'v{12,:w ^a FINAL I Tm,h &y'nt Ylm6 Notes, Remarks, Etc lt Carrier: