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ELECTRICAL-INSPECTOR RECORD APPROVALS DATE ID/SIG,COMMENTS OWNER BUILDER DELCARATION I hcrcby affrm under pcmlty of lErjury lhat I m cxcmpt fiom thc Contractos' Liccnrc ljw for thc followitrg reNg (Ssr03l.5 Busincss and Prcfcssion Cqlc): Any Cily or County which rcquircs a pcrmit lo construct. dlcr. improvc. demlish or rcIEir any structurc. pdor to its issuancc, also rcquircs thc applicant for such Jrcmit to iilc I sigrcd statcrent that hc or slrc is licensd pwant to thc prcvisiom of thc Contractor's Liccnsd hw (Chaptcr 9. Comrcrcing with Scction 7(m of Division 3 of the Busircss aid Pmfcssions Co&) or th.t hc or shc is cxcmpt thcrcfrom and thc basis for thc allcgcd cxcmption. Any violation of Setion 703 1.5 by any applicant for a pcrmit subjsts thc .pplicrnt lo a civil pcmlty of noI mrc than livc hundrcd doll{s (S500). _1, as owncr of thc propcrty, or my cmployccs with wagcs as thcir sole compensation, willdo thc work and the structure is not intcnded or offcred for salc (Scr.7044. Busincss and Professions Code: Thc Contractor's Liccnse l,rrw docs not apply to an owncr of thc propcrty who builds or funprovcs thcrcon. and who does such work hirnsclf or hersclf or through his or hcr own employces, providcd that such improvcnrcnts arc not intcndcd or olTcrcd for salc. If. howevcr. thc building or improvcrnent is sold within one year of conrplction, the Owner Builder will havc thc burdcn of proving that hc or shc did not build or irnprovc thc propc'rty for thc purgnsc of salc). _1. asowncrof thc propcrty, anrcxclusivclycontracting with liccnsed contractorsloconslrucl thc project (Scc.7W, Busincss and Prol'ession Code: Thc Contraclor's Liccnsc Law docs not apply lo an owner of propcrty who builds or improves thercon, and who contracts for such projccts with a Contractor(s) liccnscd pursuant to the Contraclor's Liccrrsc taw). _l anr cxctnpt undcr B. & P.C. for this reirson. Date: WO ITKERS' COM PENSATION DECLARATION I hcrcby affirm under pcnalty of prjury onc of thc following declarations: )24 nou"and will maintain a Ccrtificatc of Conscnt to Setf-lnsure for workers' com;rcnsarion. as provided for by Scction 3700 of thc I-abor Codc. tbr the perfbrmancc of thc work for which thc pcrmit ls issued. _l have and the work for 37fi) of the Labor Codc, for thc performancc of and policy numbcr arc: O Policy . 5-l.LL _l ccrtify that in the pcrformancc of thc work for which this pcrmit is issucd. I shall nol cmploy any person in any manner so as lo bccomc subjcct to thc workers' comgrcnsation laws of California. and agree that if I should bccomc subjcct to the workcrs' com;rcnsation provisions of Section 3700 of thc Labor Code. I shall. forthwith cornply with those provisions.. WARNING: Failurc to sccurc workcrs' c<lmlrcnsation coverage is unlawful. and shall subject an employcr to criminal penalties and civil lincs to one hundred thousand dollars ($100,000). in Io thc cost compcnsation, damages as provided for the Scction Lrbor Codc, intcrcst and attorncy's tbcs. o L ) LICI'NSI'D CONTRAC'I'OR DI'CLARATION t I hcrcby affirm undcr penalty of pcrjury that I arn liccnscd under provision of Chaptcr 9 (commcncing with Scction 7000) of Div[ion 3 of lhc Business and Profcssions Codc. and rny liccnsc is in full forcc and cffcct. t. CuOLicensc Class: Liccnse 'l 9c fl.rla. )q .<-L\ C(TNS'I'RUC'TION I,F]N I)ING,\( : I'N C}' I hcrcby affrm urder pcnalty of pcrjury th8t thsc is 8 @nstruction hndirg agcrcy for thc pcrfome of the mrk for which this Fmit is issucd (Se. 3097, Civ. C.). kndcr's Nam: [,cndcr'.s Address: APPLICANT DECLARATION I hcrcby aftirm undcr pcnalty of perjury onc of thc following dcclarations: Dcrnolition Permits-Asbcstos Notification Fcdcral Rcgulations (Title 40. Part6) _Rcqu ircd l,cttcr of Notification I ccrtifv thal thc {Z"iry,n*rhavc fedcral rcgulat ions rcgarding rcmoval are not applicablc to this projcct. read this applicaliorr ud statc the to comply with all City and County ordinanccs and Statc l-aws relating to of this City and County to entcr ug)n lhc abovc rnentioncd property for insJrcction Applicant or Agent Pernrilee nanle >( and is corrcct. I t Site-Work Underqround Pole Bases Liqht Standards Spas, Pool, Fountains Siqns (monument) Life Safetv /Low Voltaqe Fire Alarm / Dampers Communications Cable Buildins Under Slab / Floor Bondins I Groundins I UFER Transformers Torqueincl Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit)I ^r - Walts (Roush)-fiZ{l?L DtrYK 7 Ceilings (Hard & Soffit Roush JI Ceilinqs [-Bar Rouqh) lVleter Release Rouqh Service N/eter rl ? FINAL Wl)rl1/r Vf.WK 1 Notes, Remarks, Etc. -rD CJ,r.r nO on{ o I k