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ELECTR !CT{L-I NSPECTOR R ECORD <br />, nc, n7 r)n{tr <br />APPROVALS DATE ID/SIG COMMENTS -OWNER EUILDER DELCARATION <br />I hcrcby .ffirm undcr Fnalty of pcrjury thtrt I m exempt fmm Ihc Contractos' Liccns hw for thc following rcarcn (Scc.7031.5 <br />Busincss and Pmfcssion Codc): Any City or County which rcquircs a Ismit to conslruct. olter. improvc. dcmlish or rcJuir any <br />structurc, prior to its issuarcc, ds rcquircs thc applicant for such Frmit to filc a sigrcd slstcmnl that hc or shc is liccnsd pustnt <br />to the pmvisions of tlrc Contractor's Liccnrcd law (Chaptcr 9. Comrencing with Sstion 7000 of Division 3 of thc Busincss and <br />PrcfcssionsCodc)orthathcorshciscxcmptthcrcliomandthcbasisforthcallcgcdcxcmplion. AnyviolotionofscclionT03l.5byany <br />applicant for a pmit subjsts thc applicant to tr civil pcnaky of mt mrc tho fivc hund,cd dollas (5500). <br />_1. as owncr of thc propcrty, or my cmployccs with wagcs as thcir xllc compcnsalion. willdo thc work arxl thc structurc ls not <br />intendcd or ofl'crcd for salc (Scc.7044. Busincss and Professions Code: The Contractor's Liccnsc Law docs not apply to an owner of <br />thc proJrcrty who builds or improves thercnn, and who docs such work hirnself or hcrsclf or through his or hcr own cmployces. <br />provided that such inrpr<lvemcnts are not intcndcd oroffercd frlr sale. If, howcver, thc huilding or improverncnt is sold within onc ycar <br />of complction. thc Owncr Buildcr will havc thc burden of proving that hc or she did not build or improvc the propcrty for thc purposc of <br />s{lh). <br />-1. <br />as owncr of thc prolrcrty, am exclusivcly contracting with liccnscd contractors lo conslruct thc project (Scc. 7W. Busincss <br />and Pnrfcssion Codc: The Contractor's Liccnse Law docs not apply to an owner of property who builds or improvcs thcrcon, <br />and who contracts for such projccts with a Contracto(s) liccnscd pursuant to thc Contractor's Liccnsc Law). <br />-l <br />am exctnpt under Scction-, B. & P.C. for this rcason. <br />Date: Owner:- <br />WORK E l(S' C(ITVT PENSA'I'I ON <br />DFCI ARATION <br />I hcreby atfirrn undcr pnalty of pcrjury onc of thc following dcclarations: <br />-l <br />have and will maintain a Certiticatc of Consent to Self-lnsurc for workers' compcnsation, as provided for by Scction 3700 of thc <br />Labor Codc, lbr thc pcrformancc of thc work for which the pcrrnit is issued. <br />_l havc and will maintain workcrs' compcnsalion insurancc, as rcquircd by Section 3700 of the [:bor Codc. for thc pcrformancc of <br />thc work for which this pcrmit is issued. My workers' comlrcnsation insurance carricr and plicy number arc: <br />) <br />poricyNumber: 9Llg016-t",') Expires: )-Lt-- <br />_l certify that in thc perfornrancc of thc work for which this pcrnrit is issued, I shall not crnploy any pcrson in any manncr <br />so as to beconrc subjcct to thc workcrs'compcnsation laws of California. and agrec that if I should bcconrc subpct to thc <br />workers' comJrcnsation provisions of Section 3700 of thc latror Codc. I shall. forthwith comply with thosc provisions.. <br />ii <br />WARNING: Failurc to sccurc workcrs' comlrcnsation covcrugc is unlawful. and shall subict an cmploycr to criminal Jrcnaltics arkl <br />civil fincs up lo onc hundrcd thousand dollars ($100,00tt;. in addition to the cost of conrgrcnsation. darnagcs as providcd for thc <br />Scction 3076 of thc l,abor Codc, <br />Date: )-lY- )-t <br />intcrcst and attorncy's <br />o- <br />DECI-ARATION <br />I hcrcby aflirm undcr pnalty of pcrjury that I am licenscd undcr provision of Chaptcr 9 (comrrrencing with Scction 7000) of Division 3 <br />of the Busincss and Professions Codc. and my licensc is in full forcc and effcct. <br />Liccnsc C-(t)Nurnbcr:SltoQ ? <br />W <br />I hcrcby afftrm undcr Fnrlty of pcrjury that thcrc is a conslruction hnding agency for thc pcrfomrcc of thc work for which Ihis lrmil is <br />issucd (Scc. 3097. Civ. C.). <br />lrndcr's Name: <br />t <br />[,cnder's Addrcss: <br />APPLIC ANT DECLAITATION <br />I hcreby affirm under penalty of prjury one of thc following dcclarations: <br />Demolition Permits-Asbcstos Notification Federal Rcgulations (Title 40. Part6) <br />_Requircd lrtter of Notification <br />_l ccrtify that thc fedcral regulations rcgarding asbcstos renrovalarc not applicablc to this projcct. <br />_l certify that I havc rcad this application and statc that thc atnve intbrnration is corrcct. I agrcre to comply with all City and County <br />and County to cntcr upn thcorrlinanccs and Statc l.aws relating to construction. and hcrcby authorizc rcprcscntativcs of this City <br />above mcntioncd property for <br />UJ// <br />Applicant or Agcnl 7-->/ <br />Permitee name (prlnt): <br />Site-Work <br />Underqround <br />Pole Bases <br />Liqht Standards <br />Spas, Pool, Fountains <br />Signs (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Buildinq <br />Under Slab / Floor Ir <br />Bondinq I Groundinq / UFER o \W "t bA-1fl4 7 <br />Transformers <br />Torqueing ^l , I I <br />Sub-Panels 1lLK -A hl/\,'td-T7 <br />Air Conditioners t I / <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilinqs (Hard & Soffit Rouoh <br />Ceilinqs (T-Bar Rouqh)I tA <br />N/eter Release (\\g '7\b(\41t2 IV <br />\ <br />Rouqh I <br />Service N/eter v 1.9 7L t),t ffi8 7 <br />FINAL I',N\ArU .Kl <br />Notes, Remarks, Etc. <br />v - \ l- l T <br />1