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ELECTRICAL-INSPECTOR RECORD APPROVALS DATE !D/SIG.COMMENTS OWNER BUILDER DELCARATION I hcrcby trflirm undcr pcnalty of pcrjury that I m cxctrrpt from the Contractom' Lhcns ljw for lhc following rcasn (Se.7031.5 Busincss and Profcssion Codc): Any Cily or County which rcquircs s pcrmit lo snslruct. altca improvc, dcmlish or rcpair any slructurc. prior to its issuancc. also rcquircs thc applicant for such pcrmit to lilc s signcd sldcmnt th.t hc or she is li@n$d puEuut to lhc prcvisions of thc Contmctor's Liccnsd t:w (Chapter 9, Comrcncing with Setion 70OO of Division 3 of thâ‚¬ Busiress md PmfessionsCodc)orth.thcorshcLscxcmptthercfromandlhcbasisforthcslhgedcxcmption. AnyviolstionofsctbnT03l.5by.ny opplicant for s permil subtEls thc applicant to a civil penalty of nol rmrc than fivc hundrcd dollus ($50O). -1. as owncr of the propcrty, or my employccs with wagcs as thcir solc compcnsation. will do thc work and thc structure ls not intendcd or offcrcd for salc (Sec.7044. Business and Professions Code: The Contraclor's License [:w docs not apply to an owner of thc propcrty who builds or improves thereon. and who docs such work himsclf or hcrsclf or through his or hcr own employecs, providcd that such improvcnrnts are not intcrded or offercd for salc. If. howcvcr. thc tuilding or improverrcnt is sold within one year of complction. thc Owncr Buildcr will have the burden of proving that hc or shc dirJ not bnrild or improve the propcrty for the purpose of sah). -1, as owncr of thc propcrty, am cxclusivcly contracting with licensed contr&clors to construct thc projcct (Scc. 7W, Busincss and Profcssion Codc: The Contractor's Liccnse Law docs not apply lo an owner of propcrty who builds or improves thcreon. and who contracts tbr such projccts with a Contracto(s) liccnscd pursuant to thc Contractor's Liccnsc l-aw). -IamexemptundcrSection-'B.&P.C.forthisrcason.Il.. r ^.41..,-^-. WORKERS' COMPT'NS.ITION DECLARATION I hcrcby alfirrn undcr penalty of pcrjury one of the following declarations: -l havc and will maintain a Ccrtificatc of Consent to Self-lnsurc fior workers' compcnsation. as providcd for by Scction 3700 of the I-:rbor Codc, for thc pcrformancc of thc work for which thc ;rcrmit ls issucd. -l havc and will maintain workcrs' comlrcnsation insurancc. as rcquircd by Section 3700 of thc Labor Codc, for thc pcrformance of thc work for which this pcrmit is iszucd. My workers' compcnsation insurancc carricr md plicy numbcr arc: Policv Number: Exoires: _l ccrtify that in thc pcrformance of thc work for which this pcrmit is issucd. I shall not crnploy anyfrcrson in any manncr so as lo bccomc subjcct to the workcrs'compensalion laws of California, and agrcc that if I should become subjcct to the workcrs' conrJrcnsalion provisions of Scction 3700 of the [:bor Code, I shall. forthwith comply with thosc provisions.. WARNING: Failurc to riccure workers'compensation covcragc is unlawful. and shall subjcct an cmploycr to criminal penalties and civil fincs up to onc hundred thousand dollars ($100,000), in addition to thc cost of compcnsalion. danugcs as providcd for the Scction 3076 of thc l-abor Code. intcrcst and attorney's fccs. Dale:A rrnlinonl. LICENSED CONTRACTOR DECLARATION . I hercby afflrm undcr pcnalty of pcrjury that I arn liccnscd undcr provision of Chaptcr 9 (commcncing with Section 7000) of Division 3 of thc Busincss and Profcssions Code, and my licensc is in full force and effcct. Liccnse Class: License Number: W I hcrcby alfirrn undcr Jrmlty of prjury that therc is a onstruction bnding agcncy for thc 1Erfonrurce of lhc work for which this pemit is issucd (Sc. 3097, Civ. C.). lxndcr's Nam: lrndcr's Addrcss: APPLICANT DECI ARATION I trcrcby affrrm under pcnalty of pcrjury one of the following dcclarations: Demolition Pcrmits-Asbestos Notification Federal Regulations (Titlc 40, Part6) _Rcquircd l.cttcr of Notification -l ccrtify lhal thc fcdcral rcgulations rcgarding asbestos removalare not applicablc to this projcct. _l ccrtify that I have read this application and state that the above information is corrcct. I agrcrc to comply ordinanccs and Statc [,uws rclating to building construction. and hcrcby authorizc rcprcscntatives of this City abovc mcntioncd propcrty for inspcction purposes. with all City and County and County to entcr upon thc Applicanl or Agenl IDernrilee nutne ( prinl ): Date:_ Site-Work Underground Pole Bases Liqht Standards Spas, Pool, Fountains Signs (monument) Life Safety /Low Voltaqe Fire Alarm / Dampers Communications Cable Building Under SIab / 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 Rouqh Ceilinqs (T-Bar Rouqh) N/eter Release ,}e.asa,- Pcrx---r Ztr:[p -t 3-? t ftq*ir, Rough Service JMeter FINAL lO-\ t-2r EgrctP{r- Notes, Remarks, Etc. Dn., nO n cnl tr