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ELECTRICAL-INSPECTOR R ECORD APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcrcby affirm undcr pcnalty of pcrjury thal I m exempt ftom the ContractoE' Liccns kw for thc followinS rcasn (54.7031.5 Busincss and Profcssion Codc): Any City or County whhh requircs a trcrmit to construcl. altcr, improve. dcmlish or rclDr any structurc. prior to its issumc, also rcquircs the applicut for such lrcrmh to lile 8 signcd stalcmnl that hc or shc ir licctrsd pusuant to thc pmvisions of thc Contructor's Liccnsed Lrw (Chaptcr 9, Comrcncing with Setion 7000 of Division 3 of lhc Busircss and PmfcssionsCodc)orthatheorsheisexeml,tthsefiomandthebasisfortheallcgcdcxemption. AnyviolationofscctknTO3l.5byany applicant for 8 lrrmit subjtrts thc applicant to a civil penalty of not mrc than fivc hundrcd dollus ($500), _1. as owncr of the propcrty. or my employees with wagcs as their solc compcnsation. will do the work and thc structurc is not intcnded or offered for sale (Scr.704+. Business and hofessions Codc: Ttrc Contractor's Liccnsc L:w does not apply to an owner of thc propcrty who builds or improves lhereon, and who docs such work himsclf or hcrself or through his or hcr own cmployces. providcd that such improvcnrents arc not intended or offered for salc. If. howevcr. thc building or inqlrovcnrcnt is soH within onc )rcar of completion, thc Owner Builder will havc the burden of proving that hc or shc dirt not buM or inprovc the propcrty for thc purynse of salc). _1. as owncr of thc propcrty. am exclusivcly contracting with licenscd contractors lo construct thc proict (Scc. 7W, Business and Profcssion Code: Thc Contractor's Liccnse Law does not apply to an owncr of progrcrty who builds or improves lhcreon. and who contracts for such projccts with a Contracto(s) liccnsed pursuant to thc Contraclor's Liccnse l-aw). -IamexcmptunderSection-,B.&P.C'forthisrcason.Dete: Owner: uo8f,EBS3o![tENSATI0N DECI-,1\RATION I hercby affum under pcnaty of pcrjury om of the following delantions: -l havc ard will mintain a Ccrtificate of Consnt to Self-lnsre ffi rcrkeE' @mpcnstion, s ppvidcd for by Setion 3700 of the Labor Codc. for thc pofoffi of thE mrk fd which tlrc Fmit is issued. I \ill havc and will mintsin workcE' @trrpcNation iNmrce, I rEquircd by Sâ‚¬tion 3700 of the kbor Codc, for thc pcrfomce of thc work for which this pcrnrit is issued.Myt workers' compcnsation insurance carrier and prlicy nunrbcr arc: \n 4,/an'l Policy ,llrt lzt _l ccrtify that in the pcrfornrancc of the work tbr which this permit is issued. I shall not cmploy any pcrson in any manncr so as to bccornc subjcct to thc workers' compensation laws of California, and agrcc that if I should becomc subjcct to the workers' conrpensation provisions of Section 3700 of the Labor Codc, I shall, forthwith comply with thosc provisions.. WARNING: Failure to rcurc workcrs'compcnetion covcmgc is unlawlul. and shrll subFct an onploycr to aiminal pmlties and civil lincs up to onc hundrcd ahousand dollars ($100.000), in addition to thc cost of comJEns.tion, damgcs u prcvidcd for lhc Scclion 3076 of thc Latnr Codc. intcrcst and attorncy's fccs. q L IDate:_ DECI-ARATION I hcrcby affirm under pcnalty of prjury that I am licensed undcr provision of Chapter 9 (comrncncing with Sectbn 7000) of Division 3 of the Busincss and Professions Code, and my liccnsc is in full force and cffect. License cr"rs B Liccnse Number:1_ oq al W I hercby atfrm under pmlty of lErjury that therc is a construction hndhg agcrcy for the JErfomc of thc work for which this pcrmit ir issucd (Ss. 3097. Civ. C.). [-cn<lcr's Narrrc: [-cndcr's Addrcss: AIELIGANLDECiI.AMTITN I My 8trm under pen8lty of perjuy orc of rhe folbwing dElarstbns: Dcmlilion Pcrmits-Asbcstos Notificatioo FedErrl Regulations (Titlc 40, Pan6) -Required Latter of Notifrcstion -l ccnify that thc fcdenl rcgulstions rcgading ubesos remva.l re rct rpplicablc to this prcix]. th qtify tmr t Uve rc8d this apptbatiotr std state thrt thc abow infomtion is coret. I 888 to omply with 8ll City 8nd Counry 'odinares rnd State Laws rchting to buiuing @nstruction, ard hereby suthoria rcprcsnt8rires of this City 8nd Couoty lo ents upon thc atxrvc nrcntioncd propcrty ltlr purymscs. Applicant or Agenl IDernrilee name forintf: V ?.tlu'. L(V ur\r,r\Ll--l- o",. oor /o\lrz[ 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 Bonding I Grounding I UFER Transformers Torqueincr Sub-Panels Air Conditioners Roof Top Equipment Factorv Wired Unit Walls (Conduit) Walls (Roush) Ceilings (Hard & Soffit Roush Ceilinqs [-Bar Rouqh) N/eter Release Rouoh Service N/eter FINAL Notes, Remarks, Etc. GJn., nA n-7 Onl q r,;