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ELECTRICAL.I NSPECTOR RECOR D <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby allirm under pcnalty of Jrcrjury thal I m excmpt frcm Ihc ContmctoB' Liensc bw for the following rcssn (Sec.'r0315 <br />BusincsB srd Profcssion Codc): Any City or Counly which requircs a tmit to @nsaruct, altct improre, demlish or rcpair any <br />structre, prkr to its issusrce. also rcquircs thc applicant for such pcmit to file a signcd stalcmnt thar h. or drc is liccnsd pursant <br />lo thc pmvisions of thc Contrcror's Liccnsd Lrw (Ch8pter 9, Comrcrcing uith Setion 7000 of Division 3 of lhe Busims md <br />PmfcssionsCode)orthothcorsheiiexcmptthcrefrcmandthcbasisforthcallegcdcxcmption. AnyviolationofSetionT0Sl,5.byany <br />applicant for 8 pcrmit subj@ts the spplicsnl to 8 civil pcnally of nol mrc than fivc hundrcd dollss ($500). <br />_1. as owner of thc propcrty. or my cmployccs with wagcs as thcir solc compcnsalion. willdo thc work and thc stnrcturc Ls not <br />intcnded or offcred for salc (Sc,c.7044. Business and Professions Codc: Thc Contraclor's Liccnsc [:w does not apply lo an owner of <br />thc propcrty who builds or improvcs thcreon, and who does such work hirrrsclf or hcrsclf or through his or her own cmployecs. <br />providcd that such improvcnrcnts are not intcndcd or offcrcd for sah. If. howevcr, thc building or improverrcnt is sold within onc year <br />of complction. thc Owncr Buildcr will have thc burdcn of proving thal hc or she dirJ not build or improvc the propcrty for thc purtrnsc of <br />salc). <br />-1. <br />as owncr of thc propcrty, am cxclusivcly contracting with liccnscd conlraclors lo conslruct lhc projcct (Scc. 7W, Busincss <br />and Profcssion Codc: Thc Contractor's Licensc Law docs not apply to an owner of properly who builds or improvcs lhercon, <br />and who contracts frlr such projccts with a Contractor(s) liccnscd pursuant to thc Contractor's Licensc [aw). <br />-IamcxemptundcrScction-,B.&P,C'forthisreason.Date: Owner: <br />IYABIEEESQMEENSAIION <br />DEGIdSAION <br />I hcrcby 8ffirm under pendty of perjury ore of thc following dahntions: <br />-l <br />have and will mintain I Ccrtilic8tc of Conrcnt 1o Self-lnsurc for workm' compenmtion, as pmvidcd for by Sstion 37m of the <br />kbor Codc, for the pcrforc of thc mrt for which thc Imit is issucd. <br />d l"v" <br />"na <br />witt mintain workcrs' compensation insurece. &s rcquircd by Setion 3700 of thc Lrbor Codc, for the pcrfmc of <br />thc work which this pcrmit is issucd. My workers' comlrcnsation insurancc carricr and policy numbcr are: <br />rLs L o,^l <br />I'olicy C t <br />_l ccrtify that in thc pcrformance of thc work tbr which this prcrnrit is issued, I shall not ctnploy any pcrson in any manncr <br />so asto bccomc subjcct to thc workcrs'compcnsation lawsof California, and agrcc that if I should bcconrc subjcct tothc <br />workcrs' conrpcnsation provisions of Scction 3700 of thc l-abor Codc, I shall. forthwith comply with those provisions.. <br />WARNING: Failurc to siccure workcrs' compensation covcrage is unlawful, and shall subject an cmploycr to criminal pcnalties and <br />civil fincs up to onc hundrcd thousand dollars ($100.0001. in addition to thc cost of compcnsation. damagcs as providcd for the <br />Scction 3076 of thc Labor Code, intcrest and attorney's fccs. <br />Date: <br />LICENSED CONTRACTOR <br />DFCI ^ RATION <br />I hercby affirm under penalty of pcrjury that I am liccnsed under provision of Chaptcr 9 (commencing with Section 7000) of Division 3 <br />of the Business and Profcssions Code, and my liccnse is in full forcc and effect. <br />License cl^rr, G I l) License Numbcr:,oL1 C d <br />o*", ?fz/*r (lonlraclor:/r**,tryl Forctcr <br />W <br />I hcrcby amrm undcr lrcnalty of Frjury thBt thcrc is a @nstruction bnding agency for thc lErfornlmc of thc work for which this ;rrmil is <br />issucd (56. 3097. Civ. C.). <br />lrndcr's Name: <br />lrndcr's Address: <br />APPI ICANT NT'CI AITATION <br />I My affirm under pcnalty of perjury one of the following dcclarations: <br />Dcnrolition Pcrmits-Asbcstos Notification Fcdcral Rcgulations (Title 40, Part6) <br />-Required <br />l*ttcr of Notification <br />I certifv that the <br />J*"^nrtr,ot t tur" <br />fedcral regulations rcgarding asbcstos rcrnoval arc not applicable lo this project. <br />rcatl this statc that thc atnvc inforrnation is corrcct. I agrcre to comply with all City and County <br />ordinanccs and Statc Laws rclating to and hcrcby authorizc reprcscntatives of this City and <br />abovc nrcntioncd proprty for <br />Applicant or <br />Pernritee nanre ColF Lr* <br />to cntcr uJxln thc <br />Site-Work <br />Underground <br />Pole Bases <br />Liqht Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safety /Low Voltaqe <br />Fire Alarm / Dampers <br />Communications Cable <br />Buildinq <br />Under Slab / Floor tl .4, <br />Bondinq I Groundins I UFER '1 /ru/zt iLLi,SU <br />Transformers I \-./ <br />Torqueinct <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factorv Wired Unit <br />Walls (Conduit) <br />Wails (Rouqh) <br />Ceilings (Hard & Soffit Rouqh <br />Ceilinqs [-Bar Rouqh)t/ <br />N/eter Release nln/tr (u(2t I <br />7t - <br />Rouqh //.A <br />Service Meter 1 4hu/r'tt 7^u qn L7 a)/ <br />FINAL <br />Notes <br />Elrr.na n7 .)n{ tr <br />-/E <br />Applicant: