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ELECTRICAL.INSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hercby aflirm undcr pcmlty of perjury that I m excmpi ftom lhc Contractos' Liccns [lw for thc followirg rca$n (Scc.7031.5 Busincss and Pmfcssion Codc): Any City or County which rcquircs a ;rcrmit lo onslrucl, ultq, improvc, dcmlish or rcpair my struclurc. p.hr to its issuarcc. als rcquircs thc applhant for such lEmit to file a sigrcd slalcmnt thal lrc or she is liccnsd pususrt io thc prcvisions of thc Contrctor's Liccnsd trw (Chaptcr 9, Cormcncing with Scction 7000 of Division 3 of thc Business od PrcfcssionsCodc)orthathcorshcisexemptthcrcfromundthcbdsi$forthcallcgedcxcmption. AnyviolationofscctionT03l,5byany applicant for a pcrmit subjccts tlE applicant to a civil penalty of nol mrc than fivc hundrcd dou{s ($500). _1. as owncr of thc property. or my cmployecs with wagcs as thcir sole cornpcnsation. will do thc work and the structure is not intcruled or offcred for sale (Scrc.7044, Business and Profcssions Codc: Thc Contractor's License [:w does not apply to an owner of thc propcrty who builds or improvcs thcrcon. and who dclcs such work himself or hersclf or through his or hcr own employccs, providcd that such improvcnrcnts are not intcndcd or offcred for salc. If, howcvcr, thc building or improvcnrcnt is sold within onc yeiu of cornphtion. the Owncr Buildcr will havc thc burdcn of proving that hc or shc did not build or inrprove thc property for the purpose of sh). _1. as owncr of the propcrty. am cxclusivcly contracting with licenscd contractors to conslruct thc propct (Sec. 704. Busincss and Profession Codc: Thc Contractor's Liccnse Law does not apply to an owncr of propcrty who builds or improves thcrcrln, and who contracts for such projccts with a Contractor(s) licenscd pursuant to the Contractor's Licensc l-aw). _l am cxcnrpt undcr B. & P.C. a I hereby affirm under pcnalty of perjury one of the following declarations: -l have ard will maintain a Certificate of Consent to Sclf-lnsure for workcrs' compensation, Bs provided for by Section 3700 of the labor Code, for the pcrformancc of thc work for which thc prmit is issucd. -l have and will maintain workcrs' compensation insurance, as requircd by Section 3700 of thc l.abor Code, for the pcrformance of the work for which this permit ls issued. My workcrs' compcnsation insurancc carrier ard policy number arc: Carricr: Policv Numbcr: Exoires: _l ccrtify that in thc pcrforrnance of thc work for which this permit is issucd, I shall not employ any pcrson in any manncr so as to bccorrc subjcct to thc workers' compensation laws of California. and agrce that if I should becornc subjcct to the workers' comgrcnsation provisions of Scction 3700 of the L;rbor Codc. I shall. forthwilh comply with thosc provisions.. WARNING: Failure lo srccurc workers' comgrcnsalion covcrage civil fines up to onc hundred thousand dollars ($100.000). in is unlawful. and shall subjcct an employcr to criminal pcnaltics and addition to of compensation, damages as providcd for thc Scction 307(r Latror intcrcst and attorrcy's fccs. o I hcrcby affirnr undcr pcnalty of pcrjury that I am liccnsed 9 (commcncing with Scction 7000) of Divisioh 3 of lhe Business and Professions Codc, and my liccnsc is in full forcc and cffcct. Liccnsc Class: Licensc Numbcr: Date: Contractor: W I hcrcby afftrm undcr pcnalty of JErjury that thcrc is a construction hnding agcncy for thc performc of thc work for which this pcrmit is issucd (Ss. 3097, Civ. C.). lrndcr's Nanrc: lrndcr's Addrcss: APPLICANT DECI ^ RATION I trcrcby affrnn undcr pcnalty of prjury one of thc following declarations: Dcmolition Pcrmits-Asbcstos Notification Federal Regulations (Titlc 40, Part6) _Rcquircd lrtter of Notification _l ccrtify that thc f'cdcral regulations rcgarding asbcstos rcrnoval arc not applicablc to this projcct. state that with all City and County and County to cnlcr upon thc abovc nrcntioncd propcrty for inspcction Applicant or Agent P4, l> t N+f Site-Work Underqround Pole Bases Lisht Standards Spas, Pool, Fountains Siqns (monument) Life Safety /Low Voltage Fire Alarm / Dampers Communications Cable Buildins Under Slab / Floor Bondinq / Groundins I UFER Transformers Torqueinq Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rouqh) Ceilinqs (Hard & Soffit Rouqh Ceilings (T-Bar Roush) l\Ieter Release Rough Service N/eter I ;i, ) FINAL lql fl)l -T I-^^- ^t r --i) r AQ n7 Onltr f I Permilee name tprint): ( ,,,", raEla/Zoz t Notes, Remarks, Etc.,l I