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ELECTRICAL-INSPECTOR R ECOR D <br />APPROVALS DATE ID/SIG.COMMENTS OWNER AUILDER DELCARATION <br />I hcrchy affirN undcr pcnfllty of fErjury that I m cxcmpt frem thc Conlractos' Liccns law for thc following rcasn (Scc.7O3 1.5 <br />Busincss and Prefcssion Cqlc)i Any City or County which rcquircs { [Emit to construct. altcr. improvc. dcmlish or rcpair rny <br />structurc. prior lo its issuanc. alm rcquircs thc applicant for such lrcmit to filc a sigrcd statcrcnt that hc or shc is liccnsd pumrnt <br />lo thc pmvisions of thc Contractor's Liccnsd liw (Chaptcr 9. Commcncing with Scction 7000 of Division 3 of thc Busincss und <br />Prcfcssions Codc) or that hc or shc is exempt thcrcfiom and thc basis for thc rllcgcd cxcmption. Any violation of Setion 703 I .5 by any <br />applicant lbr ! Jrcrmit subjccts thc applic.nt to a civil pcnrlty of not mrc than livc hundrcd dollars (3500). <br />_1. as owncr of lhc propcrty. or my enlployces with wagcs as thcir solc compensation, will do ttrc work and the struclurc Ls not <br />intcmlcd or oll'crcd frrr salc (Scc.7044. Business and Prol'cssions Codc: Thc Contractor's Liccnsc [,aw does not apply lo an owner of <br />thc pmJxrly wh<l builds or inlprovcs thcrcon. and who dcrcs such work hirnsclf or hcrsclf or through his or hcr own cmployccs. <br />providcd that such inrprovcnrcnls are not intcnded or offcrcd for sah. lf. howcvcr. thc building or improvctncnl is sold within onc ycar <br />of conrplction. ttrc Owncr Buildcr will havc thc burden of proving lhat hc or shc did not huild or improvc thc propcrty for lhc purJxrrc of <br />salc). <br />_1. as owncr of thc propcrty, am exclusively contracting with liccnscd conlractors to conslruct thc project (Sec. 7W, Busincss <br />and Pnrtbssion Code: The Contraclor's License Law does not apply to an owncr of propcrty who builds or improvcs thcrcon. <br />and who contracts for such projects with a Contractor(s) liccnscd pursuanl to thc Contractor's License Law). <br />-lamcxcmplundcrScction-,B.&P.C.tbrthisreason.( )u ner: <br />WORKER^S' COM PENSATION <br />DECLARATION <br />I hcrcby affirm undcr pnalty of perjury onc of thc following dc.clarations: <br />_l havc and will maintain u Ccrtilicalc of Conscnt to Sclf-lnsurc for workcrs' comJrcnsation. as providcd for by Section 37fi) of thc <br />[:bor Codc. for thc pcrformancc of thc work for which thc permit is issucd. <br />[l Uu" and will maintain workers'compensation insurancc. as rcquircd by Sccrion 3700 of thc Labor Code, for thc pcrformance of <br />thc work for which this pcrmit is issucd. My workers' compcnsation insurancc carrier and policy number are: <br />C\GErrett <br />to/ otlzlporicy Nu,,rrr"r. (tn/t1- (r(t O - ct't 5f ZZ - U ? O Expires: <br />_l ccrtify thal in thc pcrlbrrnancc of thc work for which this pcrnrit is issucd. I shall not employ any person in any manncr <br />so as to bccolnc subjcct to thc workcrs' compcnsation laws of California. and agrcc that if I should bccome subject to lhe <br />workcrs' conrpcnsation provisions of Scction 3700 of thc Latxlr Codc. I shall. lilrrhwith cornply with thosc provisions.. <br />WARNING: Failurc to sccure workcrs' conrpensation covcrage is unlawl'ul. and shall subjcct an cmploycr to criminal pcnaltics and <br />civil lincs up to one hundrcd lhousand dollars (S100.000). in additiorr to thc cosl of cornpensation. datnages as providcd tbr thc <br />Sectiorr 3076 of thc Latnr Code, intcrcst and attorncy's fccs. <br />zl.tl"tn,.a^. <br />I hcrcby affirm undcr pcnalty of pcrjury that I am liccnscd undcr provision of Chaptcr 9 (comnrcncing with Scction 7000) of Division 3 <br />of thc Busincss and Profcssions Codc. and my liccnsc is in full force and cffcct. <br />Liccnsc c-(o c -{Nuntbcr:ator t 11 <br />I)rrrc. b ffv7r..r <br />W <br />I hcrcby affinD undcr Fnalty of pcrjury that therc is a @nstruclion hnding agcrcy for the pcrformnce of ihc work for which lhis lErmil is <br />issucd (Scc.3097, Civ. C.). <br />lrndcr's Name: <br />lrndcr's Addrcss: <br />ATEIICANI.DECL,AEAIIQN <br />I My0trmundcr pcnally of fErjury orc of the following dsbmtions: <br />Demlilion Pcrmits-Asbcslos Notification FcdeEI Rcgulations (Titlc ,(), Paa6) <br />_Rcquircd t tter of Notifrcalion <br />-I <br />enify that thc fcdcral rcgulations rcgarding Nbcstos rcmovalm nol epplicsblc to this pmjst. <br />-xl ccrtify thot I havc rcod this appli@tion ed state that tlrc abow infomtion is conat. I agrc to omply with all City and County <br />ordihsnccs and Stotc liws rclating to building coNtructiotr. ard hcrcby authori4 rcFcsntatives of this Cily md County to cntcr upon thc <br />abovc rrrcntioncd propcrty for inspcction purposes. <br />Applicanl or Agent <br />permiree nome rp,tnrl, GPhcrrocp OP't€S- r:U- <br />z_q <br />S:te-Work <br />Underground <br />Pole Bases <br />Liqht Standards <br />Spas, Poo!, Fountains <br />Siqns (monument) <br />Life Safetv /Low Voltaqe <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor <br />Bonding I Grounding I UFER <br />Transformers <br />Torqueinq <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Roush) <br />Ceilinqs (Hard & Soffit Rouqh <br />Ceilinqs (f-Bar Rouqh) <br />N/eter Release <br />Rouqh <br />Service N/eter <br />FINAL <br />Notes, Remarks, Etc. <br />Rev 08-07-2015