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ELECTRICAL-INSPECTOR R ECOR D <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby affrm under lEn.lty of pcrjury that I M cxcmpt frcm lhc ContracloN' Liccns ljw for lhc follouing rcasn (5€.7031.5 <br />Busincss atd hofcssion Codc): Any City or County which rcquircs s lrcmit to construct, altn, improvc, dcmlish or rcpailay <br />structurc. prior to its issumc, als rcquircs thc applicant for such permit to fih r signcd stdcmnt that hc or shc is liccnsd puzumt <br />to lhe pDvisions of thc Contractor's Liccnsd ljw (Chsptcr 9. Comming with Setion 7fi)0 of Division 3 of thc Busircss ild <br />ProfcssionsCodc)orthathcorshciscrcmptthcrcfrcmandthcbasisforthcallcgcdcrcmption. AnyviohtionofsectionT0Sl.5byany <br />applicant for a pcmit subjects lhc applicant Io n civil lEnalty of not mrc than fivc hundred dollus ($500). <br />_1, as owner of the property, or my cmployces with wagcs as thcir sole compcnsation. willdo thc work ard thc structurc is not <br />intcndcd or offcred for sale (Sec.700a. Busincss and Profcssions Code: Thc Contractor's License l-aw docs not apply to an owncr of <br />thc propcrty who build.s or improves llrcrcc,n. and who dcrcs such work himself or hcrsclf or through his or hcr own cmployccs. <br />provided that such improvcnrents arc not inlcndcd or offcrcd for salc. If. howcver, thc building or improvenEnt is sold within onc )rcar <br />of complction, the Owner Builder will have the burden of proving that hc or shc did not build or inprove thc proSrcrty for thc pur;nsc of <br />sah). <br />_1. as owncr of thc propcrty. am cxclusivcly contracting with licenscd contractors to construct thc projcct (.Scc. 7M4, Busincss <br />and Profession Codc: Thc Contractor's Liccnse Law does not apply lo an owner of propcrty who builds or improves lhercon, <br />and who contracts for such projccts with a Contractor(s) liccnscd pursuant to thc Contractor's License [aw). <br />-IamexemptundcrScction-.B.&P'C.forthisreason.Il.,r^.( l.-nn-. <br />WORKER.S' COMPENSATION <br />DECI ARATION <br />I hcrcby affirm undcr pcnalty of pcrjury onc of thc following dcclarations: <br />-l <br />have and will maintain a Certificate of Consent to Self-lnsure for workcrs' compensation. as providcd for by Scction 3700 of the <br />[:bor Code. for the pcrformancc of thc work for which thc pcrmit is issucd. <br />I <br />!L t hur" and will mainrain workcrs' compensation insurancc. as rcquircd by Section 3700 of the labor Codc, for thc pcrformance of <br />thc work for which this pcrmit is issued. My workers' compcnsation insurance carrier and plicy numbcr are: <br />Oo-I <br />Policy <br />-l <br />certify that in thc pcrformancc of thc work for which this pcrmit is issued, I shall not cmploy any pcrson in any manncr <br />so as to bccome subjcct to the workcrs' conqrcnsation laws of California, and agree that if I should bccomc subjcct to thc <br />workcrs' compensation provisions of Scction 3700 of thc l-atnr Codc, I shall, forthwith comply with thosc provisions.. <br />I{ARNING: Failurc to wurc workcrs'compcnsution covcrdgc is unlawful. and shall subjcct an cmplo5rcr to ainrinal pnnltbs and <br />civil fincs up to onc hundrcd thousand dollus ($l0o,m0). in addition to thc cost ofcomlrcnsstion. darogcs as providcd for thc <br />Scction 3076 of thc lahrr Codc, interest and attorrcy's <br />I hereby affirm undcr pcnalty of pcrjury that I am licenscd undcr provision of Chaptcr 9 (commcncing with Scc'lion 70m) of Division 3 <br />of thc Business and Profcssions Codc, and my liccnsc is in full force and effcct. <br />License Number: <br />a <br />W <br />I hcrcby afftrm undcr lEnalty of pcrjury that thm is I @nstructbn lending agercy for thc prfor@ce of lhc work for which this permit is <br />issucd (Sec. 3097, Civ. C.). <br />[-cnder's Name: <br />Lrndcr's Addrcss: <br />APILICANI.DECI.ABAUON <br />I Myaffmunds penalty of perjury orc of thc following dslamtions: <br />Demlition Permits-Asbestos Notification Fcdcrsl Rcgulstions (Title 40. Pan6) <br />-Rcquircd <br />trlttr of Norifiqtbn <br />-l <br />certify that thc fcdenl rcgul8liom rcgarding sbcstos remval re rcl applkabh lo this pDlxt. <br />&t ccnify mr I Uw rcad rhis applksrioo ard statc thar dE abovc infomtbn is comt. I rgrc to omply vith all Cily and County <br />ordimres md Slltc bws rclating to huiHing construction, ard hcrcby authori4 rcpEsr[8liB of this City aDd County to cnts upon tlE <br />above mentioncd propcrty for <br />Applicant or Agent <br />I'ernrilee name <br />purF)scs. <br />*r,, cc< l?l I z( <br />Site-Work <br />Underground <br />Pole Bases <br />Liqht Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Buildinq <br />Under Slab / Floor <br />Bondinq I Groundinq I UFER <br />Transformers <br />Torqueing <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilinqs (Hard & Soffit Rouqh <br />Ceilings (T-Bar Rouqh) <br />N/eter Release <br />Rouqh <br />Service N/eter <br />FINAL <br />Notes, Remarks, Etc. <br />Cln.r nA n7 Onl tr <br />""r", <br />O\[ C\ lt-l <br />L \Y^(.