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ELECTRICAL.INSPECTOR RECORD <br />no n7 on.t tr <br />APPROVALS DATE ID/SIG.COMMENTS +. D !OWNER BUILDER DELCARATION <br />I hcrcby aflirm undcr lrcnalty of pcrjury thal I m erempt frcm thc Contrrcto6' Licensc ljw for tlE following rcmn (Sc.7031.5 <br />Busincss aid Profcssion Code): Any City or Counly which rcquircs a lumit to construcl, alts, improvc. dcmlish or rclEir ey <br />structurc. ,rk r to ils issuance, .L$ rcquircs lhc rpplicant for such pcrmit to filc a sigrcd statcmnt that hc or dE is liccnrcd pusuant <br />to lhc pDvisions of thc Contraclor's Licensd hw (Chaptcr 9. Commncing wilh SBtion 70OO of Division 3 of thc Busircss od <br />Prcfcssions Codc) or that hc or shc is crcmpt thcrcfrom ed the basis for thc lllcgcd cxcmption. Any violation of Sstkrn 703 1.5 by any <br />applicant for a lEmit subjecls ]hc applicant to a civil pcnalty of not mrc than fivc hundrcd dollus ($500). <br />-1. <br />as owncr of thc propcrty. or my employccs with wagcs as thcir solc cornlrcnsution. will do thc work arxl thc stnrcturc is not <br />intcndcd or offcrcd for salc (Scc.7044. Busincss and Professions Code: Thc Contractor's Liccnsc Lrw docs not apply to an owner o[ <br />thc propcrty who builds or improves thcrcon. and who drrcs such work himself or herself or through his or hcr own cmployccs, <br />providcd thut such irnprovcmcnts arc not intcrrdcd or oflbrcd for sah. lf. howclcr, the building or irnprovcrncnt is sold within onc )rcar <br />of comphtion, the Owncr Buildcr will have the burden of proving thal he or she did not build or improve the propcrty fbr thc purpsc of <br />salc). <br />-1, <br />a.s owncr of thc propcrty, am exclusivcly c<lntracting with liccnsed contractors to construct thc projcct (Scc. 7W. Busincss <br />and Profcssion Codc: Thc Contractor's License Law docs not apply to an owncr of proJrerty who builds or improves lhcrcon, <br />and who conlracts for such projccts with a Contracto(s) liccnscd pursuant to thc Contractor's Liccnsc Lrw). <br />_l anr cxcnlpl undcr B. & P.C. for this reason. <br />Il.,r ^.(1.-^--. <br />WORKF' RS' COM PENSATION <br />DECT ARATION <br />I hcrcby affirrn undcr pnalty of pcrjury onc of the following dcclarations: <br />-l <br />havc and will maintain a Certifrcate of Conscnt to Sclf-lnsurc for workers' compensation, as providcd for by Scction 3700 of the <br />Labor Codc. for thc lrcrfornuncc of thc work for which thc ;rcrmit is issucd. <br />-l <br />havc and will maintain workers' comFrcnsation insurancc, as required by Section 3700 of the labor Codc, for thc lrcrfornunce of <br />thc work for which this permit is issued. My workcrs' comJrcnsation insurancc carrier and plicy number are: <br />i)n <br />Policy t ,c6 lz I lzc;zz <br />-l <br />ccrtily that in thc pcrformancc of the work for which this Jrcrmit is issued. I shall not cmploy any lrcrson in any nr&nncr <br />so as to bcconrc subject to thc workcrs' compensalion laws of California. and agrec that if I should bccorrc subjcct to thc <br />workcrs' compcnsation provisions of Section 3700 of thc [-atxrr Code. I shall. tbrthwith comply with thosc provisions.. <br />WARNING: Failurc to sccurc workcrs' compcnsation coveragc is unlawful, and shall subjcct an crnploycr to criminal pcnaltics and <br />civil fincs up to one hundred thousand dollars ($100.000). in to lhc of compensation. damagcs as providcd for thc <br />I <br />Scction 3076 of thc intcrcst and attorncy's fccs. <br />L <br />I hcrcby affirm undcr penalty of perjury that I am licensed undcr provision of Chapter 9 (cornmencing with Scction 7m0) of Division 3 <br />of the Busirtcss and Profcssions Codc, and rny liccnse is in lull force and cffbct. 'U <br />Liccnsc 'C--\O Nunrbcr: <br />o <br />a <br />W <br />I hcrcby offrm undcr lEnalty of perjury that tlm is a construdirn lcnding 8gercy for the perfome of thc eort for which this tEmit is <br />issucd (Sc. 3097. Civ. C.). <br />bndcr's Nom: <br />lrndcr's Addrcss: <br />APPLICANT DFCL ^ RTITION <br />I hcrrty affirm undcr pnalty of pcrjury one of the following declarations: <br />Dcmolition Permits-Asbcstos Notification Fedcral Rcgulations (Titlc 40. Part6) <br />-Rcquircd <br />lrttcr of Notification <br />-l <br />ccrtify that thc fcderal regulations regarding asbeslos rcmoval arc not applicablc to this project. <br />D, ccrtify that I havc read this application and state rhat rhe abovc information is correct. I agrere to comply wirh atl Ciry and County <br />ordinanccs and Statc Laws rclating to building authorizc reprcscntativcs of this City and County to entcr ulnn thc <br />abovc mcntioncd propcrty for inspection <br />Applicant or Agent <br />Pernritee <br />ion. and <br />i <br />Site-Work <br />Underground <br />Pole Bases <br />Light Standards <br />Spas, Poo!, Fountains <br />Signs (monument) <br />Life Safety /Low Voltaqe <br />Fire Alarm / Dampers <br />Communications Cable <br />Buildinq <br />Under Slab / Floor l).-\ <br />Bondinq I Groundins I UFER blq /zt Z-Ly i\t <br />Transformers I V <br />Torqueinq <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walts (Rouqh) <br />Ceilinqs (Hard & Soffit Rouqh <br />Ceilinqs [-Bar Rouqh)//.,.<- <br />lVleter Release lo/a ht ) <br />I <br />Rough I <br />Service N/eter tbl 4 / z-t LrJ -71 <br />FINAL tt>/i ht <br />Notes, Remarks, Etc.l'l <br />fJ^. <br />Dale:_