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ELECTRICAL.INSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcrcby offtrm undcr pcnalty of Frjury that I M cxctrrpt frcm thc ContmctoE' Licens lls for thc following rcasn (Sec.703l.5 Busincss and Profession Codc): Any City or County which rcquires a Jrcrm[ lo construct. oltq, improve, dcmlish or rcpair sny slructurc. prior 1o its issuare, also rcquircs thc applicant for such Fmil lo file a sigrcd statcrcnl thal he or slrc is liccnsd pususnt to rhc prcvisions of thc Contractor's Licenwd [:w (Chspts 9. Comcncing wilh Selion 7U)0 of Division 3 of thc Busircss and Prcfcssions Codc) or thut hc or shc is cxcmpt thcrcfiom ond thc basis for thc allcged cxcmption. Any violation of Setion 703 1.5 by any applicant for a Jrcrmit subjccts thc applicril to a civil pcnalty of not mrc than livc hundred dolltrs ($500). _1. as owncr of the propcrty, or my cmployces with wages as their solc comFrcnsation. willdo thc work and thc structurc is not intendcd or offered for sale (Sec.7044. Busincss and hol'cssions Code: The Contraclor's Liccnse l-aw does not apply to an owner of the propcrty wtlo builds or improvcs thereon. and who docs strch work himself or hcrsclf or through his or hcr own employccs. providcd that such improvcrnents arc not intendcd or offcrcd for salc. lf, howcvcr. thc building or improvcnrcnt is sold within onc )rar of complction, thc Owncr Builder will have thc burden of proving thal he or shc did not build or inrprove the propefiy for thc pury)osc of sah). _1. as owncr <lf thc property. am cxclusively contracting with liccnscd contractors to construct thc projcct (Scc. 7W, Busincss and Profcssion Codc: Thc Contractor's Liccnsc Law docs not apply to an owner of property who builds or improves thcreon. and who conlracts for such projccts with a Contracto(s) liccnscd pursuant to thc Contractor's License [aw). -IamcxcmptunderScction-'B.&P.C.forthisrcason. Date: WORKBRS' COMPENSATION DECI ,TRATTON I hcrcby affirm undcr pcnalty of prjury one of the following declarations: -l havc and will maintain a Cerlificate of Conscnt to Self-lnsurc for workcrs' comlrcnsation. ss provided for by Section 3700 of the I-abor Code. for the pcrformance of thc work for which thc permit is issued. -l huvc and will maintain workcrs' c()mpcnsation insurancc, as requircd by Scction 3700 of thc [:bor Code, for thc performance of the work for which this permit is issued. My workers' compensation insurance carricr and plicy number are: Policy _l ccrtity that in thc pcrformance of the work for which this prmit is issucd. I shall not employ any [rcrson in any manncr so as t<l bcconrc subjcct to the workers' compcnsation laws of California. and agrcc that if I should becornc subjcct to the workcrs' comlrcnsation provisions of ,Scction 3700 of thc labor Code, I shall. forthwith comply with thosc provisions.. WARNING: Failurc to sccure workcrs'comyrcnsation covcragc is unlawful, and shall subject an cmploycr to criminal Jrcnaltics and civil fincs up to onc hundrcd thousand dollars ($100.0O01, in addition to the cost of comlrcnsation, damagcs as providcd ftr thc Scction 3076 ot'thc Code, intcrcst and attorncy's o r I hercby affrnr undcr pcnalty of perjury that I ant under provision of Chaptcr 9 (comrncncing of Division 3 of thc Busincss and Prol'cssions Codc, and my licensc is in full force ad effcct. Liccnsc 2 Yt W I hercby allirm undcr pemlly of perjury that ttm is a @nstructk n leiding sgcrcy for the pcrfome of thc work for which lhis pemit is issued (56. 3097, Civ. C.). Lrndcr's Nanrc: [-cndcr's Address: APPI IC ^ NT DECI ^ RJATION I trrcby afrirm undcr pcnalty of perjury one of thc following dcclarations: Demolition Pcrmits-Ashstos Notification Fcderal Rcgulations (Titlc 40. Part6) _Requircd lrttcr of Nolification I ccrtifv thal thc -rltt*r ltuu" fcderal regulations rcgarding asbestos removalare not applicablc to this projcct. rcad this application and statc thal lhc atrovc inlbrnratiort is corrcct. I with all City and County ordinanccs and Statc Laws rclating to building construction. and and County to cntcr upon thc abovc mcntioned propcrty for Applicant or Agent IDernritee name 7 *,", od{oq/ur Site-Work Underground Pole Bases Light Standards Spas, Pool, Fountains Signs (monument) Life Safety /Low Voltaqe Fire Alarm / Dampers Communications Cable Buildinq Under Slab / Floor Bondinq I Groundi ns I UFER Transformers Torqueing Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit)4 Walls (Rouqh)Ct 1 Z ) (+'fi-y Ceilinss (Hard & Soffit Rouqh Ceilinqs [-Bar Rouqh)c DKEY Meter Release Rouqh Service Meter I ^t -, f) FINAL l0 I 9l',t \t\:Wfi Notes, Remarks, Etc.\r tf,nrr nQ n7 On{ E Owner:_ I)ale: b '?1lv(