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ELECTRICAL-I NSPECTO R R ECORD APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcrcby aflinn undcr frcnalty of pcrjury that I m excmpt frcm the ContrrctoG' Licenrc kw for lhc fotlowing reNn (Ss.7031.5 Busincss and Profcssion Codc): Any City or County which rcquircs s Frmit to @nstruct, alts, improvc, dcmlish or rcJnir any structre, prior to its Lssuffic, also rcquircs thc lpplhant for such Frmit to filc a signcd slrtcrcnt lhat hc or slE h licen$t tlrrsMt to thc prcvi$ions of thc Contrsctor's Liccnsd Law (Chopter 9, Comcncing wilh SNtion 7000 of Division 3 of the Business and PrcfcssionsCodc)orthathcorshcisexcmptthscfrommdthcb&sisforthcallcgcdcrcmption. AnyviohtionofsetiooT03l.5byany applicant for a pcrmit subj6ts thc appliclnt to r civil pcmhy of not mrc the fivc hundrcd dolles ($500). _1. as owncr of thc propcrty. or my cmployecs with wagcs as thcir solc com;rcnsation. willdo thc work and thc structure is not intendcd or otlcred for sale (Scc.7044, Business and Professions Codc: Thc Contraclor's License law docs not apply to an owncr of the pnlpcrty who builds or improvcs thcrcon. and who docs such work himsclf or hcrself or through his or hcr own cmployccs. providcd that such improvenrcnts arc not intcndcd or olTcrcd for srh. If. howcvcr. thc building or improvcnrcnl is sokl within onc ycar of cornpletion. thc Owncr Buildcr will havc the burdcn of proving that hc or shc did not build or improvc thc propcrty for thc purynsc of sale). -1, as owncr of the propcrty, anr cxclusivcly contracting with liccnsed contractors to construct thc pr<rject (Scc. 7W, Busincss and hofession Codc: The Contractor's Liccnsc Law docs not apply to an owncr of propcrty who builds or improvcs thcrcon, and who contracts for such projccts with a Contracto(s) liccnscd pursuant to thc Conlractor's Liccnse taw). -l am cxempt undcr Scction-. B. & P.C. for this reason. l)ale:Owner:_ WORKT'RS' COMPENSATION DECLARATION I hcreby affirm undcr pcnalty of pcrjury one of thc following dcclarations: _l havc and will maintain a Ccrtificatc of Conscnt to Sclf-lnsurc for workers' compensation. as provided for by Scction 3700 of thc Labor Code, for the pcrformance of thc work for which the permit is issucd. -l havc and will maintain workcrs' compensation insurance, as requircd by Section 3700 of the labor Code, for the pcrformancc of the work for which this pcrmit is issued. My workers' compcnsation insurance carier and policy number arc: Policy Numbcr: Expircs: _l ccrtify that in thc pcrformance of thc work for which this pcrmit is issucd, I shall not employ any pcrson in any manncr so as to becomc subjcct to thc workers'compensation laws of California. and agrcc lhat if I should bccome subpct to the workcrs' cornpcnsation provisions of Scction 3700 of thc Labor Code, I shall, tbrthwith comply with thosc provisions.. WARNING: Failure to sccure workers' compcnsalion coveragc is unlawful, and shall subjcct an cmploycr to criminal pcnalties and civil lrncs up to one hundred thousand dollars ($l00.mO). in addition to thc cost of compcnsation, damages as provided for thc Section 3076 of thc l,irbor Ccxle. intcrest and attorncy's 7 I I hercby affirrn under pcnalty of pcrjury that I anr licenscd Chaptcr 9 (cornrnencing with Scction 7m0) of Division 3 of thc Busincss and Professions Codc. and my liccnsc is in full force and cffect. )o361=\oLicenscNumbcr: W I heEby affrm undcr pcndty of perjury that thcrc is a onstrucrbn bndirg agercy for thc pcrfom of thc work for which this pemit is issucd (Scc. 3097. Civ. C.). kndcr's Nam: [-endcr's Address: APPLICANT DT'CI ARATION I hcrcby affurn under pcnalty of pcrjury onc of thc following dcclarations: Dcmolition Permits-Asbcstos Notification Fedcral Regulations (Title 40, Part6) _Rcquircd lrtter of Notification _l ccrtify that thc fcdcralrcgulations rcgarding asbcstos rcmovalarc not applicuble to this projcct. _l ccnify that I h{vc rcad this application ud statc that thc abovc infornulion is corct. I agre to comply wilh nll City and County ordinarccs and Stalc hws rclating to building conslruction, ard hcrcbyaulh)ria rcprcsilativcs ofthis City and County to cntcr upon thc above mcntioncd property for purrroses. Applicunt or Agent Permilee nanre ( print):(r'1 y'4 z.A^ -?/ .'-t I)ate:?/r> /zr Site-Work Underground Pole Bases Liqht Standards Spas, Pool, Fountains Signs (monument) Life Safety /Low Voltage Fire Alarm / Dampers Communications Cable Building Under Sl ab I Floor Bonding I Grounding / UFER Transformers Torqueinq Sub-Panels Air Conditioners Roof Top Equipment Factorv Wired Unit Walls (Conduit) Wails (Roush) Ceilings (Hard & Soffit Roush Ceilinqs [-Bar Rouqh) lVleter Release tl I ^- Rouqh q IAILT wt{>I Service lVleter ^A .-A FINAL LlY'OYI,\Dilqi,1 Notes, Remarks, Etc. fJ r-..nQ n7 r)nl tr B r