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ELECTRICAL-INSPECTOR R ECOR D APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION I hcrchy aflinn undcr pcmlry of pcrjury that I m cxcmpt frcm thc Conlraclos' Liccn$ hw for thc followinS ressn (Str.7031.5 Busincss and Profcssion Codc): Any City or Coutrty which requircs a Jrcrmit lo construcl, altcr, improve. dcmolish or rcpair any slructurc. prior to its issuance. also rcquircs lhc applicant for such lf,mdt to file a sigrcd slotcrrcnl lhat hc or shc is liccnscd pusuonl lo thc pmvisions of lhc Contractor's Liccn$d ljw (Chsptcr 9. Cormcrcing with Scction 7000 of Division 3 of thc Busircss and Pmfcssions Codc) or that hc or shc is cxcmpt thcrcfronr and lhc b6sis for thc allcgcd cxcrtrption. Any violalion of S6tk n 703 1.5 by any applicant for a pcrmit subjccts thc applic{nt to a civil pcnalty of not morc than five hundrcd dollars ($500). _1, as owncr of thc prolrcrty, or my cnlpbyccs with wtgcs as thcir solc compcnsation. willdo thc work and thc structurc is not intcndcd or ofibrcd for salc (Scc.7O14. Business and hofcssions Codc: Thc Contraclor's Liccrtsc [-aw docs not apply to an owner of thc pnrpcrty who builds or inrprovcs lhcrqrn. and who d<rcs such work himsclf or hcrsclf or through his or hcr own cntployccs, pr<lvidcd that such improvcnrcnts arc not intcndcd or ollbrcd tilr salc. lf, howcvcr. thc building or impr()vcmcnt is sold within onc ycar of cornphtion. thc Owncr Builder will havc the burden of proving that hc or shc did not build or improve the propcrty for the purpsc of salc). _1. as owncr of thc propcrty, am cxclusivcly contracting with licenscd conlractors to construct the projcct (Scc. 7U4, Business and Pnrfcssion Codc: Thc Contractor's License Law docs nol apply lo an owner of proJrcrty who builds or improvcs thcrcon. and who contracls for such projccts with a Contractor(s) liccnscd pursuant to lhc Contractor's Liccnse taw). _l arrr cxctnpt undcr Secli<ln-. B. & P.C. tbr this rea-son. Date:Owner: wtrR rn' lts, ctrMpFNLsnrltrN DECLARATION I hercby affirrn undcr pcnalty of pcrjury orrc of thc following dcclarations: _l have and will rnaintain a Certificatc of Conscnt to Self-lnsure for workcrs' compcnsation. as provided tbr by Scction 3700 of the Labor Codc. for thc performance of thc work for which thc pcrmit is issued. -l havc and will nraintain workcrs' compcnsalion insurancc, as requircd by Scct ion 37fi) of thc Labor Codc, for thc pcrformancc of thc work for which this pcrrnit is issucd. My workcrs'insurancc carricr ard policy nunrbcr arc:\tc \ 15 (o/(t2tPolicyr) _l ccrtify lhat in thc pcrltrrrnancc of lhc work ftrr which this pcrrnit is issucd. I shall nol cnrploy any pcrson in any nlanncr so as to bccorrrc subjcct lo thc workcrs'compcnsation laws ol'Califbrnia. and agrcc that if I should bcconre subjcct to the .. workcrs' conlpcnsation provisions of Scction 3700 of thc Labor Codc. I shall. forthwith conrply with those provisions.. WARNING: Failurc to sccurc workcrs' compcnsation covcruge is unlawl'ul. and shall subjcct an cnrploycr to crinrinal pcnaltics and civil lincs up to onc hundred thousand dollars ($100,000). in lo thc cost of comlrcnsation. darrurgcs as providcd lbr the Scctiorr -107(r of thc Labor Codc, intcrcst and attorncy's DrCLARATION I hcrcby atfinn under pcnalty of pcrjury that I anr liccnscd undcr provision of Chapter 9 (comrtrcncing with Scction 7000) of Division 3 of thc Busincss and Professions Codc. iurd nry licensc is in full forcc and cffect. Licensc I hcrcby affirm undcr pcnalty of perjury that thcre is a construction issued (Scc. 3097. Civ. C.). Lcnder's Nanre: agcncy for thc pcrtbrrnancc of thc work for which this pcrnrit is Lrnder's Address: AIDIDI ICANT DFCLARATION I hcrcby affrrn undcr pnalty of perjury onc of thc folkrwing dcclarations: Dcmolition Pcrrnits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40. Part6) -Reguirtd Lcttcr of Notificatiorr _l ccrlify that thc l'cdcral rcgulations rcgarding asbcstos rcrnoval arc not applicable to lhis projcct. __l ccrtily that I havc rcad this application iurd statc that the atnvc intbrnutiorr is correct. I agrce to conrply with all City arrd County ordinanccs and Statc [.aws rclating to building rcprcscntalivcs of this City and County to cnter upon thc atxrvc mcntioncd propcrty for Applicant or Agent Pcrnritee nanre lrn *,",\f*lLI Site-Work Underqround Pole Bases Light Standards Spas, Pool, Fountains Signs (monument) Life Safety /Low Voltage Fire Alarm / Dampers Communications Cable Buildinq Under Slab / Floor Bonding I Grounding / UFER Transformers Torqueinq Sub-Panels Air Conditioners Roof Top Equipment Factorv Wired Unit Walls (Conduit) Walls (Rouqh) Ceilinqs (Hard & Soffit Rouqh Ceilinqs [-Bar Rouqh) N/eter Release Rouqh Q-1-zt 2-<-1 {o Service N/eter FINAL 9-?-at .-- O{z- Notes, Remarks, Etc. [f,n,r nO n7 Onltr I Exoircs: ,rr" 'l6qt yb