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ELECTRICAL-I NSPECTOR R ECORD <br />APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby affinn undcr pcnrlty of perjury thal I m cxempt fpm thc Contnclom' Liccns [:w for thc following rcen (Ss.7031.5 <br />Busincss urd Prcfcssion Codc): Any City or County which rcquircs a lmit to construct, rlter, improvc, &mlish or rcpair any <br />structurc. prior to its issuarce, also rcquires lhc spplicsnt for such [Emit to filc a signcd stalcrcnt thot hc or shc ir liccnsd pursont <br />to thc prcvisions of the Conrrctor's Liccnrcd trw (Chaptcr 9, Comrcing with Sstion 7000 of Division 3 of thc Busincss md <br />Prctbssions Codc) or thst hc or shc is cxctrrpt thscfrom ud thc b&sis for thc allegcd excmption. Any violation of Sstion 7031.5 by my <br />applicant for a pcrmil subj$ts thc applicant to 8 civil pcnalty of trol mrc lhan livc hundrcd dotlus ($500). <br />-1. <br />as owncr of thc propcrty. or my ctnployecs with wages as their rclc compcnsation, will do thc work and the stnrture ls not <br />intended or olTcrcd for salc (Sec.7044. Busincss and hofcssions Codc: Thc Contractor's License Law does not Bpply to an owncr of <br />thc propcrty who builds or improvcs thcrcon. and who dcrcs such work himsclf or hcrsclf or through his or her own cmployccs. <br />providcd that such improvcrnents arc not intcndcd or offercd for sah. If, howcver, thc building or improvcnrcnt is rcld wilhin onc )tar <br />of conpletion. thc Owncr Builder will havc tlre burden of proving that hc or shc did not build or inrprove thc propcny for the purJnsc of <br />sale). <br />-1. <br />a.s owncr of the prolrcrty. am cxclusivcly contracting with liccnscd contractors to construcl thc projcct (Scc. 7W. Business <br />and Profession Codc: Thc Contractor's License Law does not apply to an owncr of propcrty who builds or improvcs thcreon, <br />and who contracts for such projects with a Contracto(s) licensed pursuant to the Contractor's Liccnsc [aw). <br />-l <br />am cxempt under Scction-. B. & P.C. for this reason. <br />hot-. <br />WOIIKERS' COMPENSATION <br />DECLARATION <br />I hcreby affirrn undcr penalty of pcrjury one of the following declarations: <br />-l <br />havc and will maintain a Ccrtificate of Consent to Self-lnsure for workcrs' compensation. as provided for by Sc.ction 3700 of the <br />[-abor Codc, for thc pcrformancc of thc work for which the pcrmit ls issucd. <br />_l havc and Scction 3700 of thc l-abor Codc. for thc pcrformancc of <br />carrier and policy numbcr arc:the work for <br />Policy L <br />-l <br />ccrtify that in thc pcrformancc of thc work for which this pcrmit is issucd, I shall not employ any pcrson in any manncr <br />so as to bccome subjcct to thc workcrs'compensation laws of California. and agrcc that if I should beconrc subject to the <br />workcrs' cornpcnsation provlsions of Scction 3700 of the l-ahrr Codc. I shall. forthwith comply with thosc provisions.. <br />WARNING: Failure to sccure workcrs' comlrcnsation covcragc <br />civil fines up to onc hundrcd thousand dollars ($100.000). in <br />is unlawful. and shall subjcct an cntploycr to crirninal pcnaltics and <br />addition to thc cost of compcnsation, damages as providcd for thc <br />Scction 3076 of thc Labor Codc. intcrcst and attorrcy's fccs.H <br />I hcrcby alllrnr undcr pcnalty of prjury that I am licenscd under 9 (comnrcncing with Section 7000) of Division 3 <br />of the Business and Professions Code, and my licensc is in full force and effect. <br />Liccnsc -(u Nurnbcr:b7, <br />.t <br />o*", Hlu lZt h,-'- <br />W <br />I hcrcby .fftrm undcr pcnalty of pcrjury Ihat Ihm is a ostruaion tcnaing agercy'u the g*Aorlffic of thc work for which lhis pcr;it is <br />issucd (Se. 3097, Civ. C.). <br />lrnder's Name: <br />knder's Address: <br />APPLICANT DT'CLARATION <br />I trcrc'by allirm undcr pnalty of pcrjury onc of thc folkrwing dcclaralions: <br />Dcmolition Permits-Asbestos Notification Federal Rcgulations (Titlc 40. Part6) <br />_Rcqu ircd lrttcr of Notification <br />_l ccrtify that thc federal regulations regarding asbestos rcmoval arc not applicable to this project. <br />-l <br />certify rhat I have read this frplication and state that the above information is correct. I agrc'c to comply with all City and County <br />ordinanccs and Statc laws rclating to constnrction. and hcreby authorize rcprcscnlatives of this City and County to cnlcr ulxrn llrc <br />abovc mcntioncd proprty for purposcs. <br />Applicant or Agent <br />Permitee nanre <br />,\Zt <br />Site-Work <br />Underqround <br />Pole Bases <br />Liqht Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safetv /Low Voltaqe <br />Fire Alarm / Dampers <br />Communications Cable <br />Buildinq <br />Under Slab / Floor , <br />Bondinq I Groundinq / UFER AIH,L <br />Transformers ll <br />Torqueing <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factorv Wired Unit <br />Walls (Conduit) <br />Walls (Roush) <br />Ceilings (Hard & Soffit Rouqh <br />Ceilinqs [-Bar Rouqh)I I <br />Meter Release 4l tr/>,A L{t h\tt <br />Rouqh <br />Service N/eter I <br />FINAL ahqlo,td-tA <br />Remarks Etc. <br />, <br />no on{ tr <br />a I <br />t <br />n