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ELECTRICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/S!G COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby aflirin undcr pcnalty of Jrcrjury lhsl I m cxcmpt from thc Contractos' Liccns tiw for tlrc following rclmn (58.7031.5 <br />Busrncss and Profcssion Codc): Any City or Counly which rcquircs a Frmit to construct, altcr, improvc, dcmlish or rcpair any <br />slruclurc, lrior lo its issuancc, also rcquircs thc applicant for such lrcrmit lo filc a signcd statcrenl thst hc or drc is licenscd pudmt <br />to thc Imvisions of thc Contmctor's Lrcenscd lrw (Chaplcr 9, Commcrcing with Scction 7000 of Division 3 of thc Business and <br />Pmfcssions Codc) or lhil hc or shc is cxcmpt thc.cfrom and rhc bosis for thc ollcgcd cxcmplion. Any violation of Setion 70.11.5 by any <br />ilpplicanl for I pcrmil subjcts thc applicanl lo . civil penally of nol morc thon fivc hundrcd dollars ($500). <br />-1. <br />as owncr of the propcrty. or my cnrployccs with wagcs as lhcir solc compcnsalion, will do thc work and thc structure is not <br />intcndcd or ofTcred for salc (Scr.7044, Busincss and Professions Codc: The Contractor's Liccnse Law docs not apply to an owncr of <br />thc propcrty who builds or itnprovcs thercon. and who docs such work himsclf or hersclf or through his or hcr own cmployees. <br />providcd that such improvcnrcnls arc not intcndcd or offcrcd for salc. If. howcvcr, thc building or improventnt is sold within onc ycar <br />of complction. thc Owncr Buildcr will have thc burden of proving that hc or shc did not build or improve thc propctty for thc purposc of <br />salc). <br />_1. as owner of thc propcrty, am exclusivcly contracting with liccnscd contractors to construct thc project (Sec. 7W, Business <br />and Pmfessbn Codc: The Contractor's Liccnsc Law does not apply to an owner of propcrty who builds or improves thereon, <br />and who contracts for such projccts with a Contractor(s) liccnsed pursuant to thc Contractor's Licensc [aw). <br />_l amcxcmpl undcr Scction_, B. & P.C. for this rcason. <br />I)rrIr. <br />WORKERS' COMPENSATION <br />DECLARATION <br />I hcreby affirnr undcr pnalty of perjury onc of the following dcclarations: <br />-l <br />havc and will rnaintaina Certificate of Consent to Self-lnsurc for workcrs' compcnsation. as providcd for by Section 3700 of the <br />,ffi;for the pcrformance cif the work for which the permit is issucd. <br />will maintain workers' compcnsation insurancc, &s requircd by Section 3700 of the l-abor Codc, for thc performance of <br />which this permit is iszud. My workers' compensation insurance carrier and policy number are: <br />'f <br />Policy v <br />_l ccrtify that in lhe grcrformancc of the work for which this pcrmit is issucd. I shall not cmploy any lrcrson in any manncr <br />so as to bcconrc subjrxt to the workcrs' comJrcnsation laws of California, and agrec that if I should bccome subjcct to thc <br />workers' conrpcnsation provisions of Scction 3700 of thc Labor Codc. I shall. forthwilh comply with thosc provisions.. <br />WARNING: Failurc to sccurc workcrs' compcnsation covcragc is unlawful. and shall sublt'ct an cmployer lo criminal pcnalties and <br />civil fincs up to onc hundrcd thousand dollars ($100.0m). in addition to thc cost of compcnsation, damagcs as provided for the <br />Scction 3076 of thc [:bor Codc, intcrcst and attorncy's rccs. <br />q ollzt <br />I hcrcby aftirnr undcr pcnalty of Jrcrjury that I am licenscd Chaptcr 9 (comnrcncing with Scction 7000) of Division 3 <br />of thc Busincss and Professions Codc, and my liccnse is in full forcc and cffect. <br />Liccnsc Numbcr:r,t < SsrL <br />4u IAL Con< kvah'on !n.,='r <br />W <br />I hcrcby afftrm undcr Fmlty of Frjury lhal tlm is a onstructbn lendiq 8gcrcy for the pcrfomrce of th€ mrk for whbh this permit k <br />issucd (Se. 3097. Civ. C.). <br />Lcnder's Name: <br />[-cndcr's Addrcss: <br />APPI ICANT DT'CI ARATION <br />I trcreby affrm under pcnalty of pcrjury one of the following dcclarations: <br />Dcmolition Pcrnrits-Asbcstos Notification Fedcral Regulations (Title 40. Part6) <br />-Rcqu <br />ircd l-ct tcr of Notification <br />_l ccrtify that thc fcdcral rcgulations rcgarding asbcstos rcmoval arc not applicable to this projcct. <br />_l ccrtify that I havc rcad this application afll st8te that thc above infonBlion is coret. I agrc Io comply with all City and County <br />ordinorccs and Statc ljws rclating to building construction. ad hcrcby authorire rcprcsntalivcs oflhis Cily and County to cntcr upotr lhe <br />aborc mntiorcd prcIEny for inslrcrtion purposs. <br />Applicant or Agent <br />I'crnritee nanle <br />o,r" ocl [c\ (zl <br />Site-Work <br />Underground <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 I Floor <br />Bonding lGroundinq 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 />Ceilinss (Hard & Soffit Rouqh <br />Ceilings (T-Bar Rouqh) <br />Meter Release <br />Rouqh <br />Service Nleter <br />FINAL <br />Notes, Remarks, Etc. <br />Elr'rr nO n7 Onl tr <br />f,s <br />it r h L ( aa,nlr.1