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ELECTRICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby amrm undcr lrcnalty of pcrjury lhat I m cxcmpt from the ContmcloE' Licere hw for thc following rcarcn (Sec.7031.5 <br />Busincss ond Prcfession Codc): Any City or County which rcquircs a lrcrmit to construct, alts, improvq dcmlish or rcpir any <br />sructre, prhr to its issuancc, also rcquircs lhc applicanl for such pemit to lilc a signed stalemnt that lrc or shc is liensed pu$8nt <br />to thc Imvirions of Ihc ContEctor's Liccnrcd t:w (Chaptcr 9. Comrcing with Scctiotr 7000 of Division 3 of lhc Busircss ed <br />PmfcssionsCodc)orthsthcorsheiscxcmptthcrcfromedlhebssisforthcallcgcdcxemption. AnyviolationofsetionT03l.5byany <br />applicant for a fEmit subi€ts the applicant to a civil peElty of not mrc thil five hundrcd dollus ($500). <br />_1. as owner of thc propcrty, or my employces with wages as thcir solc compensation, will do thc work and the structurc is not <br />intcndcd or ofl'cred for salc (Sc.c.7044. Busincss and hofessions Codc: The Contractor's Liccnse l.aw does not apply to an owner of <br />thc propcrty who builds or improves thcrcon. and who dcrcs such work himself or hcrsclf or through his or hcr own employccs. <br />providcd that such improvcnrcnts are nol intcrxlcd or offcrcd for sale. lf. howcvcr, thc building or improvcnrent is sold within one )rar <br />of comphtion. thc Owner Buildcr will havc the burdcn of proving that hc or shc dll not build or improve the proprty for thc purposc of <br />sah), <br />-1. <br />as owncr of thc propcrty. am exclusively contracting with liccnsed contraclors to construct thc projcct (Sec. 7W, Busincss <br />and hofcsskln Code: Thc Contractor's License Law does not apply to an owncr of proprty who builds or improves thcrcon. <br />and who contracls for such projects with a Contracto(s) liccnscd pursuant to the Contractor's Liccnsc taw). <br />-IamcxcmptundcrScction-'B'&P.C.forthisrcason. <br />Dale:_0wner: <br />WORNEIIS' COMPENS ATION <br />DF'CI ARATION <br />I hcreby affirm under penalty of perjury one of the following dc.clarations: <br />-l <br />have and will maintain a Ccrtificate of Consent to Sclf-lnsure for workers' compcnsation, as provided for by Scction 3700 of the <br />Labor Codc, for the performancc of the work for which the grcrmit is issued. <br />-l <br />have and will maintain workcrs' compensalion insurance, as rcquired by Section 3700 of the Labor Codc, for the pcrfornunce of <br />the work for which thls pcrmit is issued. My workers' compcnsalion insurance carrier and plicy number are: <br />Carrier: <br />Policv Number: Exoires: <br />_l ccrtify that in the grcrformance of thc work for which this prnrit is issued. I shall not cmploy any frcrson in any manncr <br />so as to bccomc subjcct to thc workers' comlrcnsation laws of California. and agrcc that if I should bccomc subject to thc <br />workcrs' compcnsation provisions of Section 3700 of the Latnr Code, I shall. forthwith comply with thosc provisions.. <br />WARNING: Failure lo sccurc workers' conrpcnsation covcrage is unlawful. and shall subjcct an cnrployer to criminal pcnaltics and <br />civil fincs up to one hundrcd thousand dollars ($100.0001. in addition to thc cost of compcnsation. damages as provided for thc <br />Section 3076 of the [:bor Codc, interest and attorney's fees. <br />Appllcant: <br />LICENSED CONTRACTOR <br />DF'CLAITATION <br />I hercby afTirm under pcnalty of pcrjury that I am liccnsed undcr provision of Chapter 9 (comnrcncing with Section 7000) of Division 3 <br />of thc Business and Profcssions Code, and my license is in full forcc and effcct. <br />License Class: License Number: <br />Contraclor: <br />W <br />I hcrcby aflirm undcr lrcnally of pcrjury thrt lhcrc is a construction lcndirg agency for rhe perfomncc of the work for which this pemil is <br />issucd (56. 3@7, Civ. C.). <br />lrndcr's Addrcss: <br />APPLICANT NECLARATION <br />I hcrc'by affrm undcr pcnalty of Jrcrjury one of thc following declarations: <br />Demolition Permits-Asbcstos Notification Fcdcral Regulations (Titlc 40, Part6) <br />_Rcqu ircd lrtter of Notification <br />_l ccrtity that thc fcdcralrcgulations regardirrg asbcstos rcmovalarc not applicablc to this projcct. <br />-l <br />ccnify that I havc rcod this applicslion ard slatc thal thc atnvc infomtion is corel. I agrc to @mply sith all Cilyand County <br />ordinarccs and State [aws rchting to building construction, ad hcrcbyauthoriz4 ]cprcEntaIivcs oflhis City and County to cnt6 upon thc <br />abovc rcntiorcd prcpcny for inslrtion purposs. <br />Applicant or Agent <br />Pernritee name (orint): <br />I t.r r r.. <br />Site-Work <br />Underqround <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Signs (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 />Torqueinq <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />wails (Rouqh) <br />Ceilings (Hard & Soffit Rouqh <br />Ceilinqs [-Bar Rouqh) <br />Nleter Release <br />Rough <br />Service [Vleter <br />FINAL tb tv 7t Dk#* <br />Notes, Remarks, Etc. <br />O,rr nQ n7 2n{ q <br />Date: <br />knder's Name: