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ELECTRICAL-INSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hercby uffirm undcr pcn{lry of Jrcrjury that I m cxctrlpl frcm thc ContEctor' Urcns Law for thc following rcamn (Sa.7031.5 Busincss ard Profcssion Codc): Any City or County which rcquircs a tsmit lo @nstrucl. ahs, improvc. dcmlish or rcpL my shcturc. prk r to its issuarcc, also rcquircs thc applhant for such Frmit to fih a sigred statcrcnt that hc or slrc is liccnsd pmwt to ihc prcvisions of rhc Confactor's Licensd law (Chaptcr 9, Comrercing wilh Selion 700O of Division 3 of thc Busiress ad Prcfcssions Codc) or thdt hc or shc is cxcmpl thcrcfrcm and thc basis for thc allcgcd cxemplion. Any violation of Sstion 703 1.5 by any applicant for a lrcmit subjcts lhc applicant to a civil pcnalty of not mrc lhln five hun&cd dollas ($500). -1. as owner of thc propcrty. or my cmployccs wilh wagcs as thcir solc compcnsation, will do thc work alrd thc stnrctuc is not intendcd or offcrcd for salc (Scc.7044. Business and hofessions Code: Thc Contractor's License [,aw does not apply to an owncr of the propcrty who builds or improves thercon, and who docs such work hirnsclf or hcrself or through his or hcr own cmployces. providcd that such improvcnrcnts arc not intendcd oroffcrcd for salc. lf. howclcr. thc building or improvctncnt is sold within one ycar of complction, thc Owncr Builder will have the burden of proving that hc or shc did not build or improve thc propcrty for thc purposc of sale). -1. as owncr of thc proprty, am cxclusivcly contracting with liccnsed contractors to construct thc project (Sec. 7W, Busincss and Professbn Codc: Thc Contractor's License Law does not spply to an owner of property who builds or improvcs thcrcon, and who contracts for such projccts with a Contracto(s) liccnscd pursuant to thc Contractor's Liccnsc taw). _l am undcr B.&for this rcason. o DECLARATION I hcreby affirrn undcr pcnalty of prjury onc of the following dcclarations: -l havc and will maintain a Certificate of Consent to Sclf-lnsurc frlr workcrs' compcnsation, as providcd for by Scction 3700 of the Labor Codc. for thc pcrfornuncc of thc work for which thc pcrmit is issucd. -l havc and will maintain workcrs' cornpensation insurancc, as rcquircd by Scction 3700 of the Labor Codc, for thc pcrlbrmance of the work for which this pcrnrit is issucd. My workcrs' compcnsation insurance carricr and policy number arc: I Policv Numbcr: Exoires: ?_l ccrtify that in thc prlbrmance of thc work for which this prnrit is issucd. I shall not cmploy any lrcrson in any manncr so as to bcconre subjcct to thc workers'conrpcnsation laws of California. and agree that if I should bccoutc subjcct lo thc workcrs' comJrcnsation provisions of Scction 3700 of thc L-abor Codc. I shall. forthwith comply with thosc provisions.. WARNING: Failurc to sccurc workers' compcnsation coveragc is unlawf'ul. and shall subjcct an cmploycr to criminal Jrcnaltics and civil fines up to onc hundrcd thousand dollars ($100.0U11. in addition to thc cost of comlrcnsation. darnagcs as providcd for the Scction 3076 of thc l;rtnr Codc, intercst and attorncy's fccs. I hcreby affirrn undcr pcnalty of pcrjury that I am liccnscd undcr provision 9 (commencing with Scction 7000) of Division 3 of thc Busincss and Professions Code. and my license is in full lbrce and cffect. License Class: License Number: Date: W I hercby afftrm under ,rcmlty of perjury rhat thcrc is a construction hnding agency for the perfol:lrlmc of the work for which this Jrcmit is issucd (Se. 309?, Civ. C.). knder's Nam: [.cndcr's Addrcss: APPLICANT DECLARATION I trrcby affrrm undcr pcnalty of prjury one of the following dcclarations: Dcmolition Permits-Asbcstos Notilication Fcdcral Rcgulations (Titlc 40. Part6) _Requircd l,cttcr of Notification _l ccrtify that thc fcdcral rcgulations regarding asbcstos removalarc not applicable to this projcct. _l certify thot I havc rcad this applicatiotr aod statc that thc atnvc inforrotion is corcct. I agrc to comply with all Cityand County ordimnccs and Slatc Laws rclating to building construction, afld hcrcby uulhorirc rcprc*nhtivcs ofthis Cily tr[d Counly lo cnlcr uFrn tlrc abovc mcntioncd propcrty filr inspcction Applicant or Agenl Pernritee name a Dale:Ltlot lzr Site-Work Underground Pole Bases Light Standards Spas, Pool, Fountains Siqns (monument) Life Safety /Low Voltage Fire Alarm / Damoers Communications Cable Buildinq Under Slab / Floor Bonding I Grounding / UFER Transformers Torqueinq Sub-Panels Air Conditioners Roof Top Equipment Factorv Wired Unit Walls (Conduit) Wails (Rouqh) Ceilings (Hard & Soffit Rouqh Ceilinqs [-Bar Rouqh) [/eter Release Rouqh Service Meter \ FINAL q-7* -2t U D)bt, Notes Remarks Etc.I C),-.r no n7 .)n{ tr Carrier: Datc:vt l2-\ )zt'l a I \r