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ELECTRICAL-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby afnrm undcr pcnalty of pcrjury that I m cxcmpt frcm thc CrntractoG' Liccnse llw for thc follovinS rcasn (Scc.?U3J.5 <br />Busincss ad Profcssion Codc): Any City or County whhh rcquircs a [rcmit to snstruct, altcr, improvc, dcmlish or rcpair any <br />structurc, prior to its issuarce, .l$o rcquircs thc applicant for such lErmit to filc a signcd statcmnt thst he or shc is liccnsed pursuant <br />to thc pmvisions of thc Contrsctor's Licenscd Law (Chrplcr 9. Commncing wilh Sfflion 700O of Division 3 of the Businert md <br />ProfcssionsCodc)orthathcorshciscxcmptthscfromandthcbasisforthcallcgcdcxcmption. Anyviolalionofsmtion?03l.5byany <br />applicanl for a pcrmil subjffts thc applicant to a civil pcnalty of not mrc lhan fivc hundrcd dollds (S500). <br />-1. <br />as owncr of thc property, or my cmployecs with wagcs as thcir solc comlrcnsation. willdo thc work and thc structure Ls not : <br />intended or olTcrcd for sale (Scr.704a, Business and Professions Code: The Contractor's Liccnse [-aw does not apply to an owncr of <br />the propcrty who builds or improves thcrcon, and who docs such work hirnself or hcrself or through his or hcr own cmployces. <br />provided thal such improvcments arc not intcndcd oroflered for salc. lf. howcver. thc building or improvcnrcnt is sold within onc year <br />of completion. thc Owncr Builder will havc thc burdcn of proving that hc or she did not build or inprove the propcrty for thc purpose of <br />sale). <br />-1, <br />as owner of the p,ropcrty, am cxclusively contracting with licensed contractors to construct thc projcct (Sc.c. 7W, Business <br />and Professbn Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, <br />and who contracts for such proFcts with a Contracto(s) licensed pursuant to thc Contractor's Licensc [:w). <br />_l am cxcmfrt under Section_. B. & P.C. for this reason. <br />Date: Ownen <br />WORKT'RS' COMPENSATION <br />DECI ARATTON <br />I hereby affirm undcr penalty of perjury one of the following declarations: <br />-l <br />havc and will maintain a Certificatc of Conscnt to Self-lnsurc for workers' compensation. as providcd for by Scrtion 3700 of the <br />Labor Codc, for lhc pertbrmance of thc work for which thc pcrmit is issucd. <br />#m*will nraintain workers' compcnsation insurancc. as requircd by Scction 37fi) of thc Lrbor Codc. for the lrcrformancc of <br />which this prmit is issued. My workers' compcnsation insurance carrier and plicy numbcr arc: <br />e(r <br />DL{lrtr l)>Policy <br />-l <br />ccrtify that in thc pcrformancc of thc work for which this pcrnrit is issucd. I shall not crnploy any pcrson in any manner <br />so as to bcconrc subjcct to the workcrs'compcnsation laws of California, and agrce lhal if I should becomc subjcct to thc <br />workers' cornpcnsalion provisions of Scction 3700 of thc Latnr Codc. I shall. forthwith comply with thosc provisions.. <br />WARNING: Failurc to scurc workcrs'compcnsation covcragc is unlawful. and shall suhFcl an cmplo)rcr to ciminal lrcEltbs and <br />civil fincs up lo onc hundrcd thousand dolles ($l0o,m0), in oddilion to thc cost of compcnsation, dsmgcs as providcd for lhc <br />Section 3076 of thc Codc. intcrcst and attorney's <br />t <br />r <br />DI'CI,AR/\'I'I()N <br />I hercby alfirm undcr penalty of prjury that I arn licenscd undcr provision of Chaptcr 9 (comnrcncing with Scction 7000) of Division 3 <br />of the Busincss and Profcssions Code, and my license is in full forcc and effcct. <br />License <br />W <br />I hercby afnrm undcr Fnalty of perjury that thcrc is a construction lcnding agency for thc pcrformncc of thc work for which this pcnnit is <br />issued (Scc. 3097. Civ. C.). <br />[-cnder's Nurnc: <br />Lrndcr's Addrcss: <br />APPLIC {NT NF'CLARA TION <br />I My affrnn undcr pcnalty of perjury one of thc following dcclarations: <br />Demolition Perrnits-Asbcstos Notification Fedcral Regulations (Title 40. Part6) <br />_Requ ircd l-ctter of Notification <br />ffi dffi :-dffi ffi ;ffiiffi*ffi"*:-*r**'.****?*r,,* <br />above mentioncd property for <br />( <br />Applicant or Agent <br />Pernritee nanle <br />"",",o01 16 f )f <br />Site-Work <br />Underoround <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Sions (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Buildinq <br />Under Slab / Floor <br />Bonding I Grounding I UFER <br />Transformers <br />Torqueing <br />Sub-Panels tl .a- <br />Air Conditioners 1 lLlLt rD(31) <br />Roof Top Equipment I \-/ <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Roush) <br />Ceilings (Hard & Soffit Roush <br />Ceilinss (T-Bar Rouqh) <br />N/eter Release <br />Rouqh <br />Service lVleter tl ^-- <br />FINAL 1ltlzt l(d ( 5',1 , <br />Notes, Remarks, Etc.tl -- <br />nu nQn onl <br />( <br />_Expircs: <br />/_b +CI ]t6t)l