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ELECTRICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/S!G.COMMENTS OWNER BUILDER DELCARATION <br />I hcreby afftrm undcr pemlty of lErjury thtrt I m cxempt fmm the ControctoE Liccn* Law for the fotlowing rcamn (Scc.il31.5 <br />Business ord Prcfcssion Codc): Any City or County which rcquircs a Fmit to construct. altcn improvc. dcmlish or rcpair an, <br />structrc, [rior to its issuance, also rcquircs lhe applicst for such Jrcrmit to filc a signcd strtcrcnt lhal he or slE is liccnscd pllrMt <br />lo the Imvisions of the Conretor's Liccnrcd law (Chaptcr 9, Comercing with Section 7000 of Division 3 of thc Busircss ud <br />Pmfcssions Codc) or th.t hc or shc Ls cxempt thcrcfrom and thc b$is for thc slbgcd exemlnion. Any violation of Sction 703 I.5 by any <br />applicant for a Jrcrmit subjNts thc applicant to a civil penalty of not mrc thm fivc hundrcd dollas ($5fi)). <br />-1, <br />as owrrcr of the propcrty, or my employecs with wagcs Bs thcir solc comfrcnsation. will do the work and thc structurc Ls not <br />intended or offered for sale (Sc.c.7044, Busincss and Professions Codc: Thc Contractor's Liccnse Law does not apply to an owncr of <br />the propcrty who builds or improves thercon. and who docs such work himsclf or hersclf or through his or her own employees. <br />providcd that such improvcnrcnts arc not intcnded or offerLd for salc. If, howcrrcr. the building or improvcnrcnt ls sold within onc )rar <br />of completion. thc Owner Builder will have thc burden of proving that hc or shc did not build or improrrc thc propcrty for thc purgnse of <br />salc). <br />-1. <br />as owner of thc property, am cxclusively contracting with liccnscd contractors lo construct the project (Scc. 7W. Business <br />aml Pnofession Code: The Contractor's License Law docs not apply to an owner of property who builds or improves thereon. <br />and who conlracts for such projects with a Contracto(s) licenscd pursuant to thc Contractor's Liccnse l-aw). <br />-lamcxcmptundcrScction-'B.&P.C.forthisrcason. <br />Owner:wonr<nworr <br />DECLAIIATION <br />I hereby affirm under penalty of perjury one of the following declarations: <br />-l <br />havc and will maintain a Certificate of Consent to Self-lnsure for workers' compensation, as provided for by Section 3700 of the <br />Labor Code, for the pcrformance of the work for which the frermit is issued. <br />-l <br />havc and Scction 3700 of the Labor Codc, for thc pcrformance of <br />rue:thc work for carrier ud policy <br />Policy <br />-l <br />ccrtify that in the pcrformance of thc work for which this pcrrnit is issued. I shall not cmploy any pcrson in any lnanncr <br />so as to bccomc subjcct to the workcrs' com;rcnsation laws of California, and agrce that if I should become subjcct to the <br />workcrs' cornpcnsation provisions of Section 3700 of the labor Codc, I shall, forthwith comply with thosc provisions..\ <br />WARNING: Failurc to sccure workcrs' compensation covcragc is unlawful. and shall subjcct an cmployer to criminal J:cnaltics and <br />civil fincs up to onc hundrcd thousand dollars ($100,0001. <br />Scction 3076 of the labor Code, intcrest and attorncy's fees. <br />tn thc compcnsation. damagcs as provided for thc <br />! <br />I hcrcby affirm undcr penalty of pcrjury that I am liccnscd 9 (commcncing with Scrtion 7000) of Division 3 <br />of thc Busincss and Profcssions Code, and my liccnsc is in full force and clTcct. <br />Liccnsc <br />W <br />I hcrcby ufiirm undcr Fnalty of pcrjury that lhcrc is a constructk n lcndhg agcncy for Ihe pcrformncc of the work for which this tsmit is <br />issucd (Scc. 3097, Civ. C.). <br />[rrtdcr's Namc: <br />lrndcr's Addrcss: <br />APPLICANT DF'CI ARATION <br />I trcrcty aflirm undcr pcnalty of pcrjury onc of the following declarations: <br />Dcrnolition Pcrmits-Asbestos Notification Fedcral Regulations (Title 40, Parl6) <br />_Requircd lrtter of Notification <br />-l <br />ccrtify that thc federal regulations regarding ashstos rcmoval arc not applicablc lo this projcct. <br />_l ccrtify that I havc read this application and statc that thc abovc information with all City and County <br />and County to entcr upon theordinanccs and Statc l,aws rclating to <br />abovc mcntioned propcrty for <br />Applicant or Agent <br />Pernrilee n&nre <br />and <br />I <br />Site-Work <br />Underqround <br />Pole Bases <br />Liqht Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Buildinq <br />Under Slab / Floor <br />Bonding I Grounding I UFER <br />Transformers <br />Torqueing <br />Sub-Panels <br />Air Conditioners ?-/a- ?-t As-**z <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilinqs (Hard & Soffit Rouqh <br />Ceilinqs [-Bar Rouqh) <br />N/eter Release <br />Rough ? -/F-?.t 2.^?41- <br />Service N/eter <br />FINAL V.-la,-'' ,D<aat al> <br />Notes, Remarks, Etc. <br />[f,nrr nQ n7 Onl tr <br />( <br />Date:_ <br />fiDate: f elu/tfl-t