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ELECTRICAL.I NSPECTOR R ECOR D APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcrcby affrm under trcnalty of pcrjury that I fln cxcmpt fmm thc ContEclon' Liccnsc lxw for thc following rcastr (Scc.7o3l.5 Busincss ard hofcssion Codc): Any City or County which rcquircs r Frmit to construct, allcn imprcvc, demlish or rcpsir any structurc, prior to ils issumc, alm rcquircs thc opplicmt for such lErmit to filc a signed stalcrclt that hc or shc is liensd pur$ant to thc pmvisions of thc Conrero.'s Licensd tiw (Chaptcr 9, Comcncing wilh Scction 7000 of Division 3 of thc Busircss and PrclbssionsCodc)orthathcorshciscxcmptthrcfrcmundthcbasisforthcallcgcdexcmplion. AnyviolalionofSotkrnTO3l.5byany applicant for a lrcmit subjccts thc applicant lo a civil pcnaly of not mrc than fivc hundrcd dollus ($500). -1. as owncr of thc propcrty. or my cmployccs with wagcs as thcir solc cotnlrcnsation. will do thc work ard thc struclurc is not intcnded or oll'cred lbr salc (Scc.7(X4. Busincss and hofcssions Code: Thc Contractor's Liccnse l-aw docs nol apply to an owncr of thc proprty who builds or improvcs thcrcon. and who drrcs such work hinrsclf or hcrsclf or through his or hcr own cmployccs. providcd that such improvcnrents arc not intcnded or offcrcd for salc. If, howcvcr. the building or inrprovcnrcnl is sold within one )aar of complction, thc Owncr Builder will have thc burdcn of proving that hc or she did not build or improvc thc propcrty for thc puryosc of salc). -1. as owncr of thc propcrty, arn cxclusively contracting with liccnsed conlraclors to construct thc projcct (Sec. 7U4, Business and ftotbssion Codc: The Contractor's License Law docs not apply to an owncr of progrerty who builds or improves thercon. and who contracts for such projccts with a Contractor(s) liccnsed pursuant to thc Contractor's Licensc Law). _l am cxcmpl undcr Scclion-. B. & P.C. lbr this reason. Dale: Owner: WORKERS' COMPENSATION Ihcrcbyaffirmunderpcnaltyofprjuryoneofthc,o,,o*,n*DffiHN _l havc and will maintain a Ccrtificatc of Consent to Sclf-lnsure for workcrs' comSrcnsation, as providcd for by Section 3700 of thc Labor Codc, for thc pcrformancc of the work for which the pcrmit is issucd. fy'l hun" and will maintain workcrs' compcnsation insurancc, as rcquircd by Section 3700 of thc l-abor Codc, for thc Srcrformancc of thc work for which this pcnnit is issucd. My workcrs' compensation insurancc carricr and Snlicy numbcr are: . Policy -l ccrtify that in thc performancc of the work for which this pcrmit is issucd, I shall not cmploy any pcrson in any manncr so as to bccomc subjcct to the workers' compcnsation laws of California. and agrce thal if I should becorrc subject to the workcrs' compcnsation provisions of Scction 3700 of the latnr Codc, I shall. forthwith comply with thosr provisions.. WARNING: Failurc lo sccurc workcrs' compensation covcragc civil fincs up to onc hundrcd thousand dollars ($100.000). in r is unlawful. and shall subjcct an cmptoyer to criminal pcnaltics Ind addition lo thc cost of cornpcnsation, damagcs as provkled for thc Scction 3076 of thc [:hrr Code. intcrcst and attorncy's I hcrcby allinn undcr pcnalty of pcrjury that I arn liccnscd undcr Chapter 9 (cornnrcncing with Scction 7000) of Division 3 of thc Busincss and Prot'cssions Codc, and my licensc is in full forcc and cftect. Liccnsc rc Nurnbcr:1q'U,r)r1'ap.Ir W I hcrcby affrm undcr Fn.lty of Isjury that therc is a construclion knding agercy for thc pcrfomnce of the work for which this Jrcmit is issued (Se. 3097, Civ. C.). [,cndcr's Nanrc: Lcnclcr's Addrcss: APPI ICANT DECLARATION I ffiy affrm under Jrcnalty of pcrjury onc of thc following declarations: Dcmolition Pcrmits-Asbeslos Notification Fcderal Rcgulations (Title 40. Part6) _Rcquircd lrttcr of Notihcation regarding asbestos rcnroval irrc not applicablc to this project. state that thc atrove intbrmation is corrccl. I agrce to comply with all City and County conslruction, and hcreby aulhorizc rcprcscntativcs of this City and County to cntcr uptn thc ahrvc mcntioned propcrty lbr Applicant or Agent I'ernrilee nilnle Site-Work Underground Pole Bases Liqht Standards Spas, Pool, Fountains Siqns (monument) Life Safety /Low Voltaqe Fire Alarm / Dampers Communications Cable Buildinq Under Slab I Floor / Bonding I Grounding I UFER q/csb,,J,nb^ Transformers t/tl u Torqueino v Sub-Panels Air Conditioners Roof Top Equipment Factorv Wired Unit Walls (Conduit) Walls (Rouqh) Ceilinqs (Hard & Soffit Rouqh Ceilinqs (T-Bar Rouqh) N/eter Release Rouqh Service N/eter ,I I FINAL nhy/2,JA-%\ Notes Etc. I a [fnrr nGl n7 Onl tr Date: t[ro lu&\ t