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ELECTRICAL-INSPECTOR RECORD APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION I hcrcby atfrm undcr penalty of pcrjury thsi I m cxempt ftom thc Conraclo6' Liccn$e lav for thc following rcasn (Scc.7031.5 Busincs$ and Prcfcsshn Codc): Any City or County which rcquircs a prmit to construct. alter. improve, dcmlish or rcltsf any structre. prior to its issuuce. also rcquiEs lhc applicant for such pemit lo filc a sigrcd slslercnt that he or shc b liccned puNmt to thc povisions of thc Contraclor's Liccnsd [Iw (Chaplcr 9, Comrcncing wilh Sstion 7000 of Division 3 of the Busincss md Prcfcssions Codc) or thnt hc or shc Ls cxempt threfrom and thc bssis for thc allcgcd cxcmption. Any viohtion of Sstion 7031.5 by any applicant for a pemil subjcts thc applicant to a civil penally of not mrc than fivc hundrcd dollus ($500). _1. as owncr of thc prof,crty, or my cmployecs with wagcs as thcir solc conlpensation. willdo the work and thc struc'turc is not intcndcd or otTercd for sale (Scc.7M4, Busincss and Professions Code: Thc Contractor's Liccnse [-aw does not apply to an owncr of thc propcrty who builds or improvcs thercon. and who docs such work himsclf or herself or through his or hcr own employccs, providcd that such improvcnrcnts are not inlendcd or offercd for sah. lf. hclwcvcr. thc building or improvcnEnt is sold within orc )rcar of comphtion. the Owncr Buildcr will have the burdcn of proving that hc or shc dkl not build or improvc thc property for the purynsc of salc). -1. as owncr of thc propcrty. am cxclusively contracting with liccnsed contractors to constnrct thc projcct (Sec. 7U4, Busincss and Profcssion Codc: The Contractor's Licensc Law does not apply to an owncr of propcrty who builds or improves thereon. and who contracls for such projccts with a Contracto(s) licenscd pursuant to thc Contractor's Liccnsc l-aw). -IamexemptundcrSection-.B.&P.C.forthisrcason.l)ate: WORKERS' COMPT'NSATION DECLARATION I hcrcby affirm under pcnalty of pcrjury onc of thc following dcclarations: _l havc and will maintain a Ccrtificate of Conscnt to Self-lnsurc for workcrs' compensation. as providcd for by Section 3700 of thc Labor Codc, for thc pcrforrnance of thc work for which thc pcrrnit is issued. _l havc and will maintain workcrs' compensation insurarrce, as requircd by Scction 3700 of thc [:bor Codc, for thc lrcrformancc of thc work for which this permit is issued. My workers' compcnsation insurance carrier and plicy numbcr are:5 +.CUT a,p4D\q a) 1Policy -l ccrtify that in thc pcrformancc of the work for which this pcrmit is issucd. I shall not cmploy any pcrson in any man?rcr so as to becomc subict to thc workers' comJrcnsation laws of California, and agree that if I should bccomc subject lo thc workers' compcnsation provisions of Section 3700 of thc [:bor Code. I forthwith cornply with tlmsc provisions.. WARNING: Failurc lo sccurc workcrs'cornpcnsation covcragc is and an crnployer to criminal penaltics and civil t'ines up to onc hundrcd thousand dollars ($100.000). in to the damages as providcd for thc Section thc Codc. intcrcst and altorncy's fecs. q 3o Zt I hcrcby aflirm undcr pnalty of pcrjury that I anr liccnsed under with Scction 7000) of Division 3 of thc Busincss and Professions Codc, and my licensc is in full force and cffcct.'c- lo .,0LlLiccnsc Y)23 thc lrcrformarcc o[ the work for which this pcrmit isI hercby affirm undcr pcnalty of pcrjury thal thcrc is a construction lending issucd (Scc. 3097, Civ. C.). [-cndcr's Namc: lrndcr's Address: APPLICANT NECLARATION I hcreby affinn under pcnalty of pcrjury one of thc following dcclarations: Demolition Pcrmits-Asbcstos Notification Fedcral Regulations (Title 40. Part6) _Rcquircd l-ettcr of Notification _l certify that thc fedcral rcgulations rcgarding not applicable to this project. _l ccrtify that I havc rcad this application and that thc with all City and County ordinanccs and State laws rclating to to enter upn the abovc mcntioned proJrcrty for Applicant or Agent I'ermitee nanre f f Cto o(c 5 and 3 ofzt Site-Work Underqround Pole Bases Light Standards Spas, Pool, Fountains Siqns (monument) Life Safety /Low Voltage Fire Alarm / Dampers Communications Cable Buildinq Under Slab / Floor lr Bondinq lGroundino I UFER \o 1 )>lwv I Transformers I Torqueing I ),/, Sub-Panels ,l- I /I I t \tyry2 v, Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rouqh) Ceilinqs (Hard & Soffit Rouoh Ceilinss (T-Bar Rouqh) N/eter Release Rouqh lr ,a Service N/eter il IA DWqi FINAL [0 14,1A Notes, Remarks, Etc I On., nA n-7 Onl tr Owner: /1 t bA1*ffi