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ELECTRICAL-INSPECTOR RECORD APPROVALS DATE ID/SIG COMMENTS OWNER AUILDEN DELCARATION I hcrcby aflrm undcr Fnulty of pcrjury that I m cxcmpt frcm thc ContracloN' Liansc Law for lhc following rco$n (5&'.7031.5 Busincss and Prcfession Codc): Any City or Counly which rcquircs a lErmil to construcl, alter, imprcrc, dcmlish or rcpair any structurc, prior to its issuancc, also rcquircs thc Bpplicsnt for such [rcrmit to file a signcd slalcnrcnt thrt he or shc is liccnsd pursuant to thc pmvisions of thc Contrrctor's Liccnrcd Law (Chapter 9. Conrmncing with Sstion 7000 of Division 3 of thc Busiress md PmfcssionsCodc)orthathcorsheiscxemptthcrcfromudthcbssisforthcalhgcdcxcmption. AnyviolationofSelionT03l.5byany applicant for a lE.mit subjEts lhc applicant to r civil pe nalty of nol mrc than five hundrcd dollus ($50O), _1. as owner of the propcrty. or my cmployccs with wages as thcir solc compensation. willdo the work and lhc structurc is not intended or offcrcd for salc (Sc.c.7O14, Busincss and Professions Code: Thc Contractor's Licensc l,aw does not Bpply to an owncr of thc propcrty who builds or improves thercon. and who dcrcs such work himsclf or hcrsclf or through his or hcr own cmployecs. providcd lhat such improvcnrcnts are not intcndcd oroffcrcd for salc. lf. howcvcr. thc building or irnprovcrncnt is sold within onc ycar of comphtion. the Owncr Buildcr will have thc burdcn of proving that hc or shc did not build or improvc the propcny for thc purJnsc of sah). _1. as owncr of the propcrty. am cxclusively contracting with liccnscd contracloni lo construct thc projcct (Scc. 7W, Business and t'rofcssbn Codc: Thc Contructor's License Law docs not apply lo an owncr of property who builds or improvcs thereon. and who contracts tbr such projects with a Contractor(s) liccnsed pursuant to the Conlraclor's Liccnsc Law). -lanrcxetnptundcrSection-.B.&P.C.forthisreason.Owner:_ 1VORKERS' CONI PI.'NSATION DECLARA'I'ION I hcrchy alfirm undcr pcnalty of pcrjury onc of thc following declarations: _l havc and will maintain a Ccrtificate of Conscnt to Self-lnsurc frlr workcrs' compensation. as providcd for by Scction 3700 of thc Latxrr Code. for thc pcrfornrancc of thc work for which thc pcrmit is issucd. _l have and will maintain workcrs' comlrcnsation insurance. as required by Scction 37fi) of thc labor Code. for thc ;rcrformance of thc work for which this permit is iszued. My workers' compcnsation insurance carrier and policy numbcr are: / y'o-?,z Policy _l ccrtify that in thc pcrfornrance of the work for which this pcrmit is issucd. I shall not employ any pcrson in any manncr rc as to become subpct to the workers'compcnsation laws of California. and agrce that if I should bccomc subpct lo thc workcrs' comFrcnsation provisions of Section 3700 of the [:bor Codc. I shall, forthwith comply with thosc provisions.. WARNING: Failurc to sccurc workers'compcnsation coveragc is unlawlul. and shall subjcct an crnploycr to crirninal pcnaltics and ion. damages as providctl for thccivil fincs up to one hundrcd thousand dollars tn Scction 3076 inlcrcst I hcrcby affirm under pcnalty of pcrjury that I arn liccnscd undcr provision of Chapter 9 (conrnrcncing with Scction 70m) of Division 3 of thc Business and Prof'cssions Code, and my liccnsc is in full forcc and cffcct. eo I Liccnsc W I hcrcby aflirm undcr pcnally of pcrjury that Ihcrc is a construction bnding agency for thc fErformrcc of the work for whhh this pcrmit is issucd (Se. 3097, Civ. C.). [.cndcr's Name: [,cndcr's Address: APPI ICANT NECI ARATION I hcrcby affrnn under penalty of pcrjury onc of thc following declarations: Dcmolition Permits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40. Part6) -Rcqu ircd l.cttcr of l{ot ification -l ccrtify that the fcdcralregulations rcgarding asbcstos rcmovalarc nol applicable to this projcct. statc that the above infornution is correct. I agrcc to comply with all City and County rcprescntativcs of this City and County lo cntcr upn thc abovc nrcntioncd proJrcrty for or,Applicant or Perntilee and CD Site-Work Underground Pole Bases Liqht Standards Spas, Pool, Fountains Siqns (monument) Life Safetv /Low Voltaqe Fire Alarm / Dampers Communications Cable Buildins Under Slab / Floor Bondinq I Groundins I UFER Transformers Torqueinct Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rouqh) Ceilinqs (Hard & Soffit Rouqh Ceilings (T-Bar Rough) N/eter Release Rough Service lt/eter I I tl FINAL t0/3/0,r ueilft*t6 Notes, Remarks, Etc.I [],..rr nQ n7 On1tr Dale: a Exoires: Io Date:_ \