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ELECTRICAL-INSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcrcby affum under lrculty of Frjury that I m cxcmpt ,iom thc ContrrctoB' Liensc tjw for lhc following rca$n (Ss.?031.5 Busincss and Prcfcssion Code): Any City or County shich rcquircs a lErmit to construcl, alto, imprcvc. dcmlish or rcpair uy slructure, prior to its issuance, also requires thc applicant for such lrcmit to tih a signcd strtcrcnt that hc or shc is licensd pursml k the pmvisions of thc Contretor's Liccn$d law (Chaptcr 9. Commcncing wilh Scction 7000 of Division 3 of the Business ud PmfcssionsCodc)orthathctrshciscxenptthcrcfromandthcbasisforthcnllegcdexcrption. AnyviolationofS6liooT03l,5byany upplicant for ! Ircmit subjccts thc applicant to a civil pcnalty of not mrc than fivc hundred dolltrs ($500). _1. as owncr of thc propcrty, or my cmployccs with wagcs as thcir solc comFrcnsation. willdo thc work and thc stnrcturc is not intcndcd or offcrcd for salc (Scr.7044, Busincss and Profcssions Codc: Thc Contractor's Liccnse l-aw docs not apply to an owner of the property wh<l builds or improvcs lhcrcon, and who docs such work hirnsclf or hcrsclf or thnrugh his or hcr own employecs, providcd that such irnprovcnrcnts arc not intended or offcrcd lbr salc. If. howevcr. thc building or improvenrcnt is sold within onc )aar of completion. thc Owncr Builder will havc thc burdcn of proving that hc or shc did not build or improve thc proprty for thc purlnsc of salc). _1. as owncr of thc propcrty, am cxclusively contracting with licenscd contractors to construct thc propct (Sec. 7M4, Busincss and Professbn Code: Thc Contraclor's License Law does not apply lo an owncr of propcrty who builds or improvcs thcreon, and who contracts for such projccts with a Contracto(s) liccnscd pursuant to thc Contractor's Licensc taw). _l amexcmpt undcr Scction-, B. & P.C. for this reason. I\.rin. WORKERS' COMPNNSATION DECLARATION I hcrcby affirm under pcnalty of pcrjury one of thc following declarations: -l have and will maintain a Certilicatc of Conscnt to Self-lnsure for workcrs' compcnsation, as providcd for by Scction 3700 of the I-rbor Codc. tbr thc pcrformancc of the work for which thc prmit is issued. -l have and will maintain workers' comlrcnsation insurance, as rcquired by Scction 3700 of the labor Codc, for the lrcrformancc of the work for which this permit is issucd. My workers' compensation insurance carricr and policy numbcr are: Policy a tolrq 1"^I 'l _l ccrtify thal in thc pcrformancc of the work for which this pcrmit is issued. I shall not cmploy any lrcrson in any manner so as to bcconrc subjcct to thc workcrs' compcnsation laws of California, and agrce that if I should become subjcct to the workcrs' compcnsation provisions of Section 3700 of thc Latnr Code, I shall. fbrthwith comply with thosc provisions.. WARNING: Failure to sccurc workcrs'comgrcnsation covcragc is unlawful. and shall subjcct an cmploycr to criminal pcnaltics and civil fincs up to onc hundrcd thousand dollars ($100,fin). in addition to thc cost of compcnsation. darnages as provided for thc Scction 3076 of intcrest and I hcrcby affirrn under pcnalty of pcrjury that I arn liccnscd undcr provision Chaptcr 9 (comrrrcncing with Scction 7000) of Division 3 of the Busincss and Professions Codc, and rny liccnsc is in full forcc and effcct. Liccnse q? Nunrbcr: W I hcrcby aflirm undcr pcnalty of perjury that thcrc is a @nstructbn hnding agency for the pcrformrce of thc work for which this pcrmit is issucd (Sc. 3097, Civ. C.). [.ender's Namc: Lrndcr's Addrcss: APPI ICTNT NT'CI ARATION I trercby affirm undcr penalty of pcrjury onc of thc fbllowing declarations: Dcmolition Pcrmits-Asbcstos Notification Fedcral Regulations (Titlc 40. Part6) _Rcqu ircd l-ctter of Notification ( _l ccrtify that thc federalrcgulations asbcstos rcmovalarc not applicablc to this projcct. --.l ccrtify that I have rcad I agrcc to conrply with all City and County ortlinanccs and Statc laws abovc nrcntioncd proprty for A;lplic:url or Agcrtl ot' :.,?^'?"",":"*"* Site-Work Underqround Pole Bases Liqht Standards Spas, Pool, Fountains Siqns (monument) Life Safety /Low Voltage Fire Alarm / Dampers Communications Cable Buildinq Under Slab / Floor Bondinq I Groundino I UFER Qltbh,Jr^2<) Transformers 1l Y Torqueinq Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rouqh) Ceilinqs (Hard & Soffit Rouqh Ceilinss (T-Bar Rouqh) [Vleter Release Rough I Service Nleter nlftht *K'lp FINAL I Yl-\ 7,o Notes Remarks Etc. [Jr.r, nO n7 ')n{ tr Expires: "",", g /r(/A Permitee name (print):_ t