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ELECTRICAL.INSPECTOR R ECORD <br />APPROVALS DATE ID/S!G.COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby affrm undcr penalty of pcrjury that I m cxcmpt ftom the ContrrcloF' Licen$ ljw for thc followiig rcen (Sec.7031.5 <br />Business ard Profession Codc): Any City or County which requircs a pcrmit lo construcl. allcr. improrc. dcmlish or rcpoir oy <br />structrc. Fior to its issuarce. als rcquircs thc applkant for such pemit to lilc a sigrcd statcmnl thsl hc or slre is licnsd pwant <br />to the ltrovisions of tlE Coilractq's Liccnsd kw (Chspter 9, Comrcing with Scction 7000 of Division 3 of the Busiress and <br />PrcfcssionsCodc)orthatheorshciscxemptthqcfromandthcb6sisforrhcallcgcdexcmplion. AnyviolalionofScctbntO3t.St!any <br />applicant for a pcrmii subFcts the lpplicant to a civil pcmlty of not mrc than five hundrci dolles (S5m). <br />-1. <br />as ouncr of thc JroJfny, o. my cmplo)es vith vogcs as thcir mle comlEnsation. willdo thc wtrk ord thc sinEtre is mt <br />intcrdcd or offmd for slc (Se.7(X4, Business and Prcfcssions Code: Th€ Contractor's Liccnr llw dcs not apply to an owner of <br />thc preJrcny who builds or inprcws themn. md who d@s rch rcrk himself or hcrsclf or thrcugh his or hcr own employccs, <br />prcvidcd Ihat such imprcrcrcnls rc not htendcd or oflcrcd for mh. If, howcrct the buik ing or imprewmnt is sH within ore }t{ <br />of smplction, the Owner Builder will harc ttE burdq of prcving th0l lrc or she dil mt boiH or iryrcrc frc pp]rcrty for the pupos of <br />uh). <br />_1. as owncr of fie prcpcny. am exclusivcly contrlcting with lien*d contr.ctoF to @nstruct thc pmjcct (Scc. 7(X4, Busircss <br />and Pmltssim Code: The Conrretor's License Law d@s not .pply Io e owncr ofprclErty who builds or imprcves thseon. <br />and who @ntncts for such pmjccls wilh 8 Contncto(s) lhcns{ purswl lo thc Contraclor's Liccns [rw). <br />-l <br />am cxcmpt undcr Sclion-. B. & P.C. for this rcasn. <br />Date: Owner:- <br />WORKF' RS' COMPENSATION <br />DECLARATION <br />I hcrcby affrm under frenalty of perjury onc of the following declarations: <br />_l havc and will maintain a Ccrtificatc of Consent to Self-lnsurc for workers' compcnsation, as provided for by Section 3700 of the <br />l:txlr Code, for thc perfornunce of the work for which the pcrmit is issued. <br />l-, nur" and will maintain workcrs' compensation insurancc, as required by Scction 3700 of thc Labor Codc, for the performance of <br />thc work for which this permit is issued. My workcrs' compensation insurance carricr and policy numbcr arc: <br />?.rL-qL.rc L\aU^-., *tl <br />Prticy Nu,r,u"r' F [.-U L 1-t1F\ Expircs:eltlLL <br />_l ccrtiti that in lhe grcrforrnancc of thc work for which this permit is issucd. I shall not employ any pcrson in any manncr <br />so as to bccomc subjcct to thc workcrs'contpcnsation laws of California. and agru'c that if I should bcconrc subict to the <br />workcrs' compcnsation provisions of Scction 37fi) of thc lahrr Code. I shall. forthwith conrply with thosc provisions.. <br />WARNING: Failurc to sccure workcrs' comJrcnsation coverage is unlawful. and shall subjcct an cmployer to criminal penaltics and <br />civil tincs up to one hundred thousand dollars ($l00.Un), in addition to thc cost of conrlrcnsation. damages as provided for thc <br />Scction 3076 of the labor Codc. intcrest and attorncy's fccs. <br />Date: <br />LICENSED CONTRACTOR <br />DECLARATION <br />I hcrcby affirrn undcr penalty of pcrjury that I arn liccnscd under provision of Chaptcr 9 (commcncing with Section 7000) of Division 3 <br />of thc Business and Prot'essions Code, and my licensc is in full force and effect. <br />Liccnsc Nurnbcr:r 0tq6!tq <br />tt <br />W <br />I hcrcby affrm undr penally of pcrjury thsl lhsr is 8 @nstruclbn lerding sgcrcy for thc Jrcrfomrce of thc wok for whhh this pcrmil ii <br />issucd (56. 3097, Civ. C.). <br />kndq's Narc: <br />Lcndcr's Addrcss: <br />A PPLICA NT NF'CLARATION <br />I hcrcby affirm under penalty of perjury onc of thc following declarations: <br />Dcmolition Pcrmits-Asbestos Notification Fedcral Rcgulutions (Title 40. Part6) <br />-Rcquired <br />l*ttcr of Notification <br />_l ccrtify that thc federal regulations rcgarding asbcslos rcmovalare not applicable lo this projcct. <br />/ t ccnifythat I have rcad this application ud state lhar thc above infornration is corrcct. I agrcc lo cornply <br />I reprcsenlativcs of this City <br />with all City and County <br />and County to cntcr uprn thcordinanccs and Statc l,aws relating to <br />abovc nrcntioned propcrty for inspection <br />Applicant or Agent <br />Permitee nanre <br />construction. and hcrcby authorize <br />1A <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 />Building <br />Under Slab / Floor rl <br />Bondins lGroundinq I UFER ld" n-lat,e <br />Transformers tt IV <br />Torqueinq <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilinss (Hard & Soffit Rouqh <br />Ceilings (T-Bar Rough) <br />lVleter Release <br />Rouqh \ <br />Service N/eter lol,tolu <br />FINAL \:/, t 17t .Ku <br />Notes, Remarks, Etc.{ <br />,l <br />na n7 0n{ q <br />Applicant: <br />clurr, b (D <br />.l actrA