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ELECTRICAL.INSPECTOR R ECO R D <br />Dn., nO n7 Dnl tr <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcreby aflirm undcr lrcnalty of Frjury that I m cxempl frcm thc ContractoF' Liccns ljw for lhc followin&rcasn (Scc.70ll.5 <br />Busincss and Prufcssion Codc): Any City or County which rcquircs a Ismit Io construcl. altca improvc. dcmolish or rcp4ir any <br />structurc, prior to its issuancc, als rcquircs thc applicml for such lEmit to filc a sigrcd stutcmnt thal hc or shc is licensed pusuant <br />lo thc prcvisions of thc Conractor's Liccnrcd law (Chaptcr 9. Commencing with Scction 7000 of Division 3 of lhe Busincss snd <br />PrcfcssionsCodc)orthathcorshciscxemptlhcrcfromandthcbosisforthcallcgcdcxcmption. AnyviolationofSethnTO3l.5byany <br />applicrnt for a [rc]mir subjects thc applicant to a civil pcnrlty of not mrc than fivc hundrcd dollus ($500). <br />_1. as owncr of thc propcrty, or my cmployccs with wagcs a.s thcir solc compcnsation. willdo thc work and thc structurc Ls not <br />intendcd or olTcrcd lbr salc (Scr.7044, Business and Profcssions Culc: Thc Contraclor's Liccnse law does not apply to an owncr of <br />thc proprty who builcls or improvcs thcrcon. and who docs such work himsclf or hcrsclf or through his or hcr own cmployees. <br />providcd that such inrprovcnrcnts arc not intcnded or offcrcd ftrr salc. lf. howcvcr. thc building or intprovcnrcnl is sold within onc ycar <br />of completion. tlrc Owncr Buildcr will have thc burdcn of proving that hc or she did not build or improve the proprty for the purpose of <br />salc). <br />-1, <br />as owncr of thc propcrty. am cxclusivcly contracting with liccnscd contractors to construct the propct (Scc. 7W, Busincss <br />and Profcssion Codc: Thc Contraclor's Liccnsc Law docs not apply lo an owncr of propcrty who builds or improves thercon. <br />and who contracts for such projects with a Contracto(s) liccnscd pursuant to lhc Contractor's Liccnse l-aw). <br />_l am cxcmpt ts.t <br />Z z, <br />1VORKERS' COt\I PUNSATION <br />DECI ARATION <br />I hercby affirm undcr pnalty of perjury onc of the following dcclarations: <br />_lhaveanclwill rnaintainaCertificatcofConscnttoSclf-lnsurcforworkers'compensation,as providedforbySection3T00ofthc <br />Labor Codc. lbr thc pcrformance of the work ftrr which thc pcrmit is issucd. <br />-l <br />have and will maintain workers' comlrcnsation insurance, as rcquircd by Section 3700 of the l-abor Codc, for thc grcrformancc of <br />thc work for which this pcrmit is issued. My workers' compcnsation insurance carrier and plicy number arc: <br />Carricr: <br />Policy Numbcr: Expircs: <br />_l ccrtify that in thc pcrformancc of thc work fbr which this permit is issucd. I shall not cnrploy any pcrson in any nranncr <br />so as to bcconre subjcct to the workers' compcnsation laws of California. and agrce that if I should beconrc subjcct to the <br />workcrs' compcnsalion provisions of Scction 3700 of thc l-atnr Codc. I shall, forthwith cornply with thosc provisions.. <br />* <br />WARNING: Failurc to liecure workers' compcnsation covcragc is unlawful. and shall subjcct an entploycr lo cripinal pcnaltics and <br />civil fines up lo onc hundred thousand dollars in addition to the cosl corrtpcnsation, damagcs as provided for thc <br />Scction 3076 tt <br />LIC I.]NS F:I ) CON'tRA C"I'O R <br />DECII\RATION <br />I hcreby affirrn undcr pcnalty of pcrjury that I am licenscd undcr provision of Chapter <br />of the Busincss and Prof'cssions Code. and my liccnse is in full forcc and effect. <br />9 (comnrcncing with Section 7000) of Division 3 <br />License Class: Licensc Number: <br />I)ate: <br />W <br />I hcrcby alf[m undcr tEmlty of perjury that thcrc is a construc,rion lcnding agcncy for lhc pcrfomnce of thc work for which this pcmil is <br />issucd (Se. 3097. Civ. C.). <br />hnder's Namc: <br />lrnder's Address: <br />APPLICA NT DF'CLARATION <br />I trcrc'byafinnundcr pnalty of pcrjury one of thc following dcclarations: <br />f)crnolition Perrnits-Asbcstos Notification Fcdcral Regulations (Titlc 40. Part6) <br />_Rcquircd lrt tcr o f Notification <br />-l <br />certify lhat the <br />_l ccrtify that I have <br />feOcru\Iffphtions rcgarding asbcstos renrovatarc not applicablc ro this project. <br />rcad this application md state that thc atnvc infortnation with all City and County <br />ordhanccs and Statc l-aws rclating to building <br />above mcntioncd propcrty tbr <br />Applicant or Agent <br />aPernritee <br />and lo cnter <br />Z/ <br />Site-Work <br />Underground <br />Pole Bases <br />Light 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 />Torqueinq <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 />Ceilinqs (T-Bar Rouqh) <br />N/eter Release <br />tl .-{) <br />Rough I lU l'fl o I MN <br />Service N/eter I <br />F!NAL tolTt ,l)^lCr^Notes, Remarks, Etc rl \LJ <br />I <br />r P <br />Conlractor:_ <br />v4DdQ- <br />I ,I <br />I