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ELECTRICAL.INSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcrcby affrm undcr Fnally of Frjury thrt I m cxempt from the Contracto6' Licctrs liw for thc following rcasn (Sec.7031.5 Busincss ard Prcfcssion Codc): Any City or County vhich rcquircs a ;mmit lo constmt, alts. imprcre, dcmlish or rclnir rny structurc. prior to its issuarcc. 8ls requircs thc rpplicant for such pcmit lo filc a signcd statemnt that hc or shc is liensd pursut lo lhc pmvisions of thc Contractor's Licensd tiw (Chaptcr 9, Commcrcing wilh SEtion 70fl) of Division 3 of lhe Business lnd PrcfcssionsCodc)orthathcorsheiscxcmptthcrcfromandthebasisforlhcallcgcdcxcmption. AnyviolstionofSEtionT03l.5byany applicant for a pcrmit subjet$ thc applicant to a civil pcnalty of not mrc thu fivc hundrcd dollils ($500), -1, as owner of the proFrcrty. or my employccs with wagcs as thcir sole compcnsation. will do the work and thc structure is not intcndcd or offercd for sale (Sec.7044. Business and hofcssions Code: The Conlractor's Liccnse law docs not apply to an owner of thc propcrty who builds or improves thercon. and who does such work himsclf or hcrsclf or through his or her own employees. provided that such improvenrnts arc not intendcd or offcred for salc. lf, howevcr. thc building or improvcnnnt is sold within onc ycsr of complction, the Owncr Buildcr will have the burdcn of proving that he or shc did not build or impmve thc property for thc purgnsc of sah). -1. as owncr of thc propcrty. Bm exclusively contracting with liccnscd contractors lo construct thc projcct (Scc. 7W, Business and Prrofession Codc: The Contractor's Licensc Law does not apply lo an owncr of property who builds or improves thereon, and who contracts for such projects with a Contracto(s) liccnscd pursuant to thc Contractor's Liccnsc kw). -lamexcmptundcrSection-.B.&P.C.forthisreason. I).r ln. WORKERS' COMPENSATION DECLARATION I hcrcby atfirrn undcr pcnalty of pcrjury one of thc following dcclarations: _l have and will maintain a Certifrcate of Conscnt to Self-lnsure for workcrs' compensation. as pmvidcd for by Section 3700 of the l;rbor Codc, for thc ;rcrlbrmancc of the work for which thc prmit is issued. _l have and by Section 3700 of the [:bor Codc. for thc pcrformancc of the work for carrier ud polhy number are: + Itrlicy t^JC $-A (-L -l ccrtify that in thc pcrforrnance of the work for which this permit is issucd, I shall not cmploy any lrcrson in any manncr so as to bccorne subjcct to thc workers' compcnsation laws of California, and agrce that if I should bccornc subject to thc workers' compensation provisions of Section 3700 of thc Labor Code, I shall, forthwith comply with thosc pmvisions.. WARNING: Failurc to liecurc workers' conrlrcnsation covcrage is unlawful. and shall subjcct an cnrpl<lycr to criminal pcnaltics and civil fincs up lo one hundred thousand dollars ($100.000), in addition to lhc Section 3076 of thc [:bor Codc, intcrest and altorrcy's fccs. compcnsation, damages as providcd for thc oatet /D *4,^2 \ I hercby affirm undcr pcnalty of prjury that I am liccnsed under provision of Chapter 9 (comnrencing with Scction 7000) of Division 3 of the Busincss and Profcssions Code, and my liccnsc is in full force and cffect. l-iccnsc Nurnbcr:o /O'{a1Il., i -. W I hcrcby affum under Fmlty of pcrjury that thcrc is r @nstructbn bnding agcncy for lhc trrforlwcc of thc work for whbh this fmit is issucd (Se. 3097. Civ. C.). [.cndcr's Namc: lcnder's Addrcss: APPI ICANT DECI ARATION I hcrcby affrmundcr Jrcnalty of perjury onc of thc following dcclarations: Dcmolition Pcrmits-Asbcstos Notification Federal Regulations (Title 40. Part6) _Rcquired [rttcr of Notification _l certify that thc fedcral rcgulations rcgarding asbcstos rcmovalare not applicablc to this project. Site-Work Underground Pole Bases Liqht Standards Spas, Pool, Fountains Signs (monument) Life Safety /Low Voltaqe Fire Alarm / Dampers Communications Cable Building Under Slab / Floor Bonding I Groundins I UFER Transformers Torqueincr Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) walls (Rouqh) Ceilings (Hard & Soffit Roush Ceilinqs [-Bar Rouqh) Meter Release Rouqh Service N/eter FINAL /o-?o-?,I1.Fil, tl Z Notes, Remarks, Etc Eln,, nO n7 ,n{ tr as Exoires: _l ccrtify that I havc rcad this application and state that thc above information with all City and County and County to enter uprn thcordinanccs and State Laws rclating to building construction, abovc rnentioncd profrcrty for inspcction purposes. Applicant or Agent Permitee name (print):._An& t,L C- fc(a *n lb*-Zr