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ELECTRICAL-INSPECTOR R ECOR D <br />APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby allirm undcr Fnalty of Frjury that I m cxcrnpt ftom the ContractoN' Liccnsc l:w for thc following rca$n (56.7031.5 <br />Busincss arxl Profession Codc): Any City or County which rcquircs a 1rcrmit lo construct. altcr. improvc. dcrclish or rcpair uny <br />structurc, prhr to its issuarcc, also rcquircs thc applicant for such 1rrmil to lilc ! signed stotcrent thd hc or shc is licensed pursuanl <br />to thc prcvisions of the Contractor's Liccnsd law (Chaptcr 9. Comrencing wilh Setion 700O of Division 3 of lhc Busincss and <br />ProlbssionsCodc)orthathcorshciscxcmptthscfrcmandthcbmisforthcallcgcdcxcmplion, AnyviohlionofSetion?03l.5hyany <br />Bpplicrnt for B Frmit subjets thc opplicant to o civil pcnally of not mrc than fivc hundrcd dolles ($500). <br />_1. as owner of thc propcrty. or my cmployecs with wagcs as their sole com[rcnsalion. willdo the work and thc structure is not <br />intcndcd or offcred for salc (Scc.7B4. Business and Profcssions Code: The Contractor's Liccnsc [-aw docs not apply lo an owncr of <br />thc prcFrty who builds or improvcs thcrcrrn, and who dcrcs such work himsclf or hcrsclf or through his or hcr own cmployccs. <br />providcd that such improvcnrcnls arc not intended or oftbrcd for sah. If. howcver, the building or improverpnt is sold wilhin onc ycar <br />of conrplction, thc Owncr Buildcr will havc thc burdcn of provirrg that he or shc did not build or improve the propcrty for the puryrcsc of <br />salc). <br />_1. as owncr of thc proprty. am cxclusivcly contracting with liccnscd contractors lo construct thc projcct (Scc. 7044. Business <br />and Pmlbssion Codc: Thc Contractor's Liccnsc L,rrw docs not apply to an owner of proJrcrty who builds or improves thcreon. <br />and who contracls for such projccts with a Contractor(s) liccnscd pursuant lo thc Contractor's Licensc Law). <br />-latttcxemptundcrScction-'B.&P.C.forthisrcason. <br />Dale:_Owner:_ <br />g!8f,E8$5]O!4IENSAUQN <br />DECI.A8AtrON <br />I hcrcby affum undcr pcnalty of pejury one of the following dslmtioN: <br />-l <br />have rnd will miilain a Ccdifrcale of CoNnt to Sclf-lnsurc for rcrkss'@mFnsalion. as povitcd for bySalion 3700 of lhe <br />Iabor Code, for thc tEfomncc of the work for which the pcrmit is issued. <br />)CI havc and will mintain workcrc' compensation insurance, ss requircd by section 37OO of the trbor Codc, for the perforw of' thc work for which this permit is isscd. My workqs' compensation insuBnce cuier ard policy number re: <br />2-l 1* lt*Policy q5 <br />T <br />_l ccrtify that in the pcrlbrrnancc of the work for which this Jrcrmit is issued. I shall not cmploy any pcrson in any manner <br />so as to bcco:ne subjcct to thc workers' compensation laws of California, and agrce that if I should becomc subjcct to the <br />workcrs' compcnsation provisions of Scction 3700 of thc Labor Codc, I shall, lbrthwilh comply with thosc provisions.. <br />WARNING: Failure to sccurc workcrs' conrpcnsation covcruge is unlawful. and shall subjcct an cmpl<lycr to crinrinal pcnaltics and <br />civil lincs up to onc hundrcd thousand dollars (Sl00.ffD). in addition to thc cosl of comJrcnsation. damagcs as provided for thc <br />Scction 3076 of thc Labor Codc. intcrcst and attorrrcy's fccs. <br />Applient:_ <br />I hcrcby aftirrn undcr pcnalty of pcrjury that I ant liccnscd of Chaptcr 9 (cornmcncing with Scction 7000) of Division 3 <br />of thc Busincss and Profcssions Codc, and my liccnsc is in full forcc and cffcct. <br />Liccnsccrorr, &tO LicenseNumbcr: \OZ-'UoeqL <br />D"r.' 41 \(l ai conrracro'' M Orn.zr^.hn^^ ( of, r <br />W <br />I hcrcby afftrm undcr pemlty of Frjury th.t therc is o onstruction lending agcrcy for thc lrcrformncc of thc work for whhh this lrcmit ir <br />issucd (Ss. 3097, Civ. C.). <br />[-cndcr's Nanrc: <br />kndcr's Address: <br />APPLICANT DT'CI ARATION <br />I hcrcby aflirrn under pcnalty of pcrjury onc of thc following dcclarations: <br />Demolition Permits-Asbestos Notification Federal Rcgulations (Title 40. Part6) <br />_Rcqu ircd lrttcr of Notification <br />-l <br />ccrtity that the federalrcgulations rcgarding asbcstos removal arc not applicablc to this project. <br />{"*rfy rhat I have read this application and state that rhc abovc informarion is corrcct. I agree ro conrpty <br />ordinanccs and Statc Laws rclating to building construction. and hcrcby authorizc rcprcscrltutivcs of this City <br />with all City and County <br />and County to cntcr upon thc <br />abovc mcntioncd propcrty for <br />Applicant or Agent <br />Permitee name <br />purposcs. <br />Site-Work <br />Underqround <br />Pole Bases <br />Liqht Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Buildinq <br />Under Sl ab I Floor ,l I <br />Bondinq I Groundinq I UFER lo .1, .I .ACO <br />Transformers t v <br />Torqueinq u <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilinqs (Hard & Soffit Rouqh <br />Ceilinqs (T-Bar Rouqh) <br />l\4eter Release <br />Rouqh <br />Service JVIeter ( <br />FINAL \-x.u <br />Remarks Etc. <br />no n7 Dn1 tr <br />Dare: c<\ tgl u.r <br />""", <br />glylt, l