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ELECTRICAL.I NSPECTOR R ECOR D APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION I hcrcby amrm undcr Fnilry of perjury that I u exempt from thc ContractoE' Licenrc l:w for lhe following rc&$n (Ss.703ir5 Busincss and Prcfcssion Codc): Any City or County which rcquircs a fsmit to construcl, trlter, improvc, demlish or qBir uy structuc. prhr to its issuqncc, also rcquircs the .pplicot for such Frmil to filc a sigrcd st.tcrent that he or shc k liccn*d pmmt to the prcvisions of the Contractor's Licenrcd l"rw (Chaptcr 9. Commencing wilh Setion 7000 of Division 3 of thc Busincss and PrefcssionsCodc)orthathcorshciscrcmptthercftomandthebasisforthclllcgcderemption. AnyviolalionofSctionT03l.5byany epplicant for I lErmit $ubjccts the applicant to r civil penalty of not mre than five hundrcd dollus ($5fi)). _1. as owncr of thc propcrty, or my employces with wagcs as thcir sole conrpcnsation, will do thc work and thc stnrcturc is not intcndcd or otTcred for salc (Scc.7044. Busincss and Professions Code: Thc Contraclor's Liccnsc law does not apply lo an owncr of thc proJrcrty who builds or improves thcrcon. and who docs such work hinrself or hcrsclf or through his or hcr own cmployccs. providcd that such inrprovcnrnts are not intcrxlcd or offcrcd for sah. If. howcver. thc building or improvcnrcnt is rcld within onc ytar of complction, the Owncr Builder will havc thc burdcn of proving that he or shc did not build or intprovc thc propcrty for thc purynse of 'uh). _1, as owncr of thc propcrty. am cxclusivcly contracting with liccnscd contractors to conslruct thc pnljcct (Scc. 7W, Busincss and Profcssion Codc: Thc Contraclor's License Law does not apply lo an owner of property who builds or improves thercon. and who contracts fbr such projccts with a Contractor(s) liccnscd pursuant to thc Contractor's Liccnsc taw). -IatncxenrplundcrScction-'B.&P.C.forthisrcason. Owner: wo Rxn' ts' cour pn'rrLsl rro) x DECI ARATION I hcreby affirm under Srenalty of pcrjury one of the following declarations: -l havc and will maintain a Certifrcate of Consent to Sclf-lnsurc for workcrs' compensation. as providcd for by Section 3700 of the l,abor Code, for the performancc of the work for which thc permit ls issued. _l havc and will maintain Section 3700 of thc labor Codc, for thc pcrformance of thc work for which this carricr and number arc: o ,rS CA ea Con? Policy (F o o _l ccrtify that in thc pcrtbrmancc of the work for which this pcrrnit is issucd, I shall not crnploy any person in any manncr so as to bccomc subjcct to thc workcrs' comgrcnsation laws of California. and agrec that if I should beconrc subjcct to the workcrs' cornpcnsation provisions of Scction 3700 of the labor Codc, I shall. lbrthwith cornply with thosc provisions.. WARNING: Failure to stcurc workcrs'compcnsation covcragc is unlawful. and shall subject an cmployer to criminal pcnaltics and civil tines up to one hundrcd thousand dollars ($100,000), in addition to thc6ost of comgrcnsation, damagcs as provided for thc Scction 3076 of thc Labor Codc, intercst and attorrrcy's t'ccs, D,,"., Lr-\Lt -L[ ffi,'* 8", [) f, ' I hcreby affirm undcr pcnalty of pcrjury that I arn liccnsed undcr provisit of Chaptcr 9 (commcncing with Section 7000) of Division 3 of thc Busincss and Profcssions Codc, and nry liccnse is in full force and cffect. . Liccnsc ,a Qtnlt) D",.. r L.l -lL{-21 rt ciY \a W I hcrcby affrm undcr lEnllty of pcrjury that thcrc is a constructbn lcnding agcncy for thc perforlmce of thc work for which this permit is issued (56. 3@7. Civ. C.). lxndcr's Namc: [.cnder's Addrcss: APPLICANT DECLARATION I trcrcby affrnn under penalty of pcrjury onc of thc following declarations: Dcmolition Pcrmits-Asbestos Notification Fcderal Regulations (Title 40, Part6) -Requircd l.cttcr of Notification Site-Work Underground Pole Bases Light Standards Spas, Pool, Fountains Siqns (monument) Life Safety /Low Voltaqe Fire Alarm lDampers Communications Cable Buildinq Under Slab / Floor Bonding I Grounding I UFER Transformers Torqueinq Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rouqh) Ceilinqs (Hard & Soffit Rouqh Ceilinqs [-Bar Rouqh) JMeter Release Rough 4 -t?-2t Wt?L/a Service Nleter FINAL 9-19-?,tu{42 Notes, Remarks, Etc. -s, Dr.rr nO n7 Onl tr Date:_ -Expir"#- rcmovalare not applicablc to this projcct. intbrnutio:r is corrcct. I agrce to conrply with all City and County rcprescntatives of this City and County to cnter upn thc abovc mcntioncd property for Applicant or Agent Pernritee nanre @ H,p+t.ra I)atc:, Ll"Itl '2,112