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ELECTRICAL-INSPECTOR RECORD Qnr no n7 r,nl tr APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION I hcrcby afftrm undcr lEnally of pcrjury thot I m excmpt ftom thc Contracto6' Licensc lrw for Ihe following rcasgn (Se.7031.5 Busincss ard Profc$sion Cqlc): Any City or Couily whkh rcquircs { pcmit to construct. allq. imprcvc. &mlish or rcpair any structurc. prk r to its issuane, also rcquircs thc applicanl for such Jxrmil to filc a signcd statcmnt that hc or shc is liccnsd pttalant to thc prcvisions of thc Contrelor's Liccnsd llw (Chaptcr 9. Commcncing wilh Setion 7000 of Division 3 of thc Busincss and PrclbssionsCodc)orlhsthcorshcisexempllhqcfrcmandthebasisforlhcallcgcdcxcmplion. AnyviolnlionofSetionT0.ll.5byony applicanr for a pcnnit subjccts thc opplicant to u civil pcnally ofnot nmrc lhan livc hundrcd dollus (5500). _1. as owncr of thc propcrty. or my cmployecs with wagcs as their solc conrpensation. will do thc work and lhe structure is not intcndcd or offcrcd lbr sale (Sc.c.70l4, Busincss and hofessions Codc: Thc Contraclor's Licensc [:w docs not apply to an owncr of thc pnr;rcrty who builds or impnlvcs thercon. and who dcrcs such work hirnsclf or hcrsclf or through his or hcr own cmployecs. providcd that such inrprovcnrcnls arc not intcndcd or offercd for sale. If. howcvcr, thc building or improvenrnt is sold within onc ycar of conrplction, thc Owncr Buildcr will havc thc burdcn of proving that hc or shc did not build or improvc the propcrry for thc purynsc of salc). _1. as owner of thc property. arn cxclusivcly contracting with liccnscd contractors to construct thc projcct (Sec. 7W, Busittcss aM Profcssbn Codc: The Contractor's Licensc Law docs not apply lo an owner of proJrcrty who builds or improves lhcrcon. and who contracts for such pr<rjccts with a Contractor(s) licensed pursuant to thc Contractor's Liccnse Law). _l am cxempt undcr Section_, B. & P.C. for this rcason. Date: Owner: WORKF'RS' COMPT'NSATION DF'CLARATION I hcrcby affirm undcr penalty of prjury onc of the following declarations: -l have and will maintain a Ccrtificatc of Conscnt to Self-lnsure for workcrs' compensation, as provided for by Section 3700 of the [:bor Codc, for thc pcrformancc of thc work for which thc pcrmit is issucd. \r/nur"and will maintain workcrs'compcnsation insurancc. as rcquircd by Secrion 3700 of thc l-abor Codc, for thc Srcrformancc of the work for which this permit is issued. My workers' compensation insurance carricr and plicy number are: poticy Nu^*r, bNVVC- o 15776 o Expires:04/a/zL _l ccrtily that in the performancc of the work for which this permit is issucd. I shall not employ any person in any manncr so as to bccomc subjcct to thc workcrs' compcnsation laws of California, and agrcc lhat if I should beconp subjcct to the workcrs' comlrcnsation provisions of Section 3700 of thc L^abor Code. I shall. forthwith comply wilh thosc provisions.. WARNING: Failurc to securc workers'conrpcnsation covcrage is unlawful. and shall subjcct an crnploycr lo crirninal pcnaltics and civil t'incs up to onc hundred thousand dollars (S100.0ffi1. in addition to thc cost of comlrcnsation. danugcs as providcd for thc Scction 3076 of thc labor Codc. intcrest and attorncy's l'ccs. Dare:og/)t/zt I hercby afTirm undcr pcnalty of pcrjury that I arn licenscd under provision of Chaptcr 9 (comnrencing with Section 7000) of Division 3 of thc Business and Professions Code, and nry license is in full forcc and effect. Liccnsc I Nunrbcr: loZSbLT Dil",o8/t?1Ll &t'r W I hcrcby aflirm under lrcnalty of pcrjury th.t thcrc is a construction bnding agcrcy for rhc pcrformcc of thc work for which lhis JEmit is issucd (Ss. 3097. Civ. C.). lrndcr's Namc: [-cnder's Address: APPLICANT DECLARATION I lrrcby afl-urn undcr pnalty of pcrjury onc of thc following declarations: Demolition Pcrmits-Asbcstos Notification Fcdcral Regulations (Titlc 40. Part6) _Rcqu ired lrttcr of Notification _l ccrtify that thc fcdcral rcgulations rcgarding asbcstos rcmovalare not applicablc to this projcct. _l ccrtify that I havc rc8d this application ard slatc that thc atnvc infomtion is coret. I age lo comply with rll City and County ordinrrccs and Statc kws rclating to buiHing consrudion. rnd hcrcby autluirc rc[trcscntotives of this City and County to cnlcr upon lhc abovc rrrcntioncd propcrty for Applicant or Agent I'ernritee nanre Dare: P7/ tg/ Z t Site-Work Underqround Pole Bases Light Standards Spas, Pool, Fountains Siqns (monument) Life Safety /Low Voltaqe Fire Alarm / Dampers Communications Cable Buildinq Under Slab / Floor t, Bonding I Grounding I UFER ?/rrr/",JAEI Transformers rl /v Torqueincr Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Roush) Ceilinqs (Hard & Soffit Rouoh Ceilinqs (T-Bar Rouqh) N/eter Release Rouqh Service N/eter I ,I FINAL q/t-hr ll z-: Remarks Etc. t Applicant:_ Sol*rr