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ELECTRICAL.INSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcrcby affrm undcr penalty of JErjury thst I m cxcmpt frcm thc ContretoN' Liccnrc law for llE follosing re.sn (Ss.7031.5 Busincss ard Prcfcssion Cqlc): Any City or Counly which rctuircs s pcrmit to construcl. altcr imprcve. dcmlish or rcIEit my structuc. prior to its issuancc, aLrc rcquircs Ihc applicant for such prmit to filc a sigrcd statcmnt that hc or slrc is licensd purruail to thc povisions of thc Contractor's Liensed lrw (Chaptcr 9, Comncing with Sfftion 7000 of Division 3 of the Busiress and PDfcssionsCodc)orthathcorshciscxcmptthcrcfrommdthcbasisfortheallcgcdcrcmption. AnyviohlionofScdionTo3l.5byany applicant for a Jrcrmit subjsts thc applicant to a civil pemlty of not rmrc lhan fivc hundrcd dollus ($500). -1. as owncr of thc propcrty, or my cmployees with wages as thcir solc compcnsation. will do thc work and thc stnrcture is not intendcd or offcred for sale (Scrc.7044, Busincss and hofessions Codc: Thc Contractor's License l-aw docs not apply to an owner of thc property who build.s or improves thcreon, and who does zuch work himsclf or hcrself or through his or her own cmployces. provided that such improvcnrcnts are not intcrdcd or offcrcd for sah. lf. howevcr. thc building or improvcrrcnt is sold within onc )tar of completion, the Owncr Builder will have thc burdcn of proving that he or she did not build or improve the propcrty for the purpose of sale). _1. as owncr of thc propcrty, am exclusivcly contracting with licenscd contractors to construct the project (Sec. 7W, Business ard Professkrn Codc: The Contractor's Licensc Law docs not apply to an owncr of propcrty who builds or improves thcrcon, and who contracls for such projccts with a Contracto(s) licenrcd pursuant lo thc Contractor's Licensc taw). -Iamexcmr,tunderSection-'B.&P'C.forthisreason.n..a^. WORKERS' COMPENSATION DECLAITATION I hcrcby afllrrn undcr pcnalty of prjury onc of thc following dcclarations: -l have and will maintain a Ccrtificate of Consent to Self-lnsurc for workers' compensation, as providcd for by Section 3700 of thc l^abor Codc. for thc lrcrformancc of thc work for which thc pcrmit is issucd. -l havc and will maintain workers' compcnsation insurance, as requircd by Scction 3700 of thc labor Code, for the pcrformancc of thc work lbr which this Jrermit is issued. My workers' compensation insurancc carrier and Jrclicy number arc: Policy Numbcr: Expircs: _l ccrtify that in lhc performance of the work for which this permit is issued. I shall not employ any pcrson in any manncr so as to bccornc subpct to the workers' com;rcnsation laws of California. and agrcc that if I should beconrc subject to the workcrs' compcnsation provisions of Section 3700 of the Labor Codc, I shall, forthwith comply wilh those provisions.. WARNING: Failurc to sccure workcrs'compcnsatiotl coveragc is unlawful. and shall subject an cmployer to criminal Jrcnaltics and civil fincs up to one hundred thousand dollars ($100,000), in addition to thc cost of com;rcnsalion, damagcs Bs provided for the Scction ol'thc Codc, intcrcst and attorrrcy's fccs. (4 Aoolicnnt: W \{"\rl% udNsiu-c6xrnnc'rtrn@ I hcrcby affirm undcr pcnalty of Srcrjury that I am licenscd under provision of Chaptcr 9 (cornrncncing with Scction 7000) of Division 3 of thc Busincss and hofcssions Codc. and my liccnsc is in full force and effcct. Liccrrsc o Numbcr:15bzoel L I hcrcby affirm under pcnalty of perjury that thcrc is a construction lending agency issued (Scc. 3097, Civ. C.). [.endcr's Name: thc pcrfonnancc of thc work for which this permit is Lrnder's Address: APPI ICANT DECLARATION I trcrcby affrrm undcr ;rcnalty of pcrjury one of thc following declarations: Demolition Pcrmits-Asbestos Notification Federal Rcgulations (Title 40, Part6) _Requircd lrttcr of Notification _l ccrtify that the federalrcgulations regarding asbcstos rcmovalarc not applicable to this projcct. _l ccrtify that I havc rcad this application and information is corrcct. I agree to comply with all City and County ordinanccs and Statc [:ws rclating to authorizc representativcs of this City and County to cntcr ulnn thc above lncntioncd proprty for inspection Applicant or Agent Pernrilee name ( print ): tlrc ci L Site-Work Underground Pole Bases Light Standards Spas, Pool, Fountains Signs (monument) Life Safety /Low Voltage Fire Alarm / Dampers Communications Cable Buildinq Under SIab / Floor Ir /^ Bondinq I Groundinq I UFER f(,)-T ,\b,it{+Y7 Transformers tl Torqueing Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rouqh) Ceilinqs (Hard & Soffit Rouqh Ceilings (T-Bar Rouqh),I .-, lMeter Release IC Dkfrr>'7 / Rough Service N/eter o ')7t >kY>7 FINAL Notes, Remarks, Etc. D,.rr r nA n7 On t tr I E4lz^ /