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ELECTRICAL-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG COMMENTS OWNER BUTLDER DELCARATION <br />I hcrcby affrm under Fnalty of Jrcrjury thal I m crcmpt frcm thc ConmcloB' Lhcn* hw fot lhe followitrg rcaon (Sc.7031.5 <br />Busincss and Profcssion Codc): Any City or County which rcquircs a lErmil to @nstruct, altcr, improvc. dcmlish or rcpair any <br />structurc, prior to its issuance. also rcquircs thc applicant for such Frntt to lilc a signcd statcrent thst hc or shc is liccnsd pusuant <br />to lhc ,trovisions of thc Contractor's Licenscd kw (Chaplcr 9. Commcrcing with S$tion 7000 of Division 3 of the Busircss and <br />ProfcssionsCodc)orrhalhcorsheiscxcmptthcrcfromudthcbaslsfortheallcgcdcxcmption. AnyviolationofS€tion703l.5byany <br />applicant for a pcrmil subjffts thc applicant to a civil pcnalty of not rmrc than tivc hundrcd dollrs ($500). <br />_1. as owncr of thc propcrty, or my cmployces with wagcs as their solc comF,cnsation, willdo thc work and $c slrLtcture ls nol <br />intcndcd or offcrcd for sale (Scc.7044, Busincss and Profcssions Codc: The Conlractor's Licensc [:w does not apply to an owncr of <br />the propcrty who builds or itnprovcs thcrcon. and who docs such work himsclf or hcrsclf or through his or hcr own ernployccs. <br />providcd that such improvcnrnts arc not intcrxlcd or offcrcd for salc. lf. hcrwevcr. thc building or improvcnrcnt is mld within onc ytar <br />of cornphtion. thc Owncr Buildcr will have thc burdcn of proving thal hc or she did not build or improvc thc propcrty for the purynsc of <br />salc). <br />_1. as owncr of the propcrty. am cxclusively contracting with licenscd contractors to conslruct thc projcct (Sec. 7W. Busittcss <br />and Profcssion Codc: The Contractor's License Law docs not apply to an owncr of property who builds or improvcs thercon. <br />and who contracts for such projccts with a Contractor(s) liccnscd pursuant to thc Conlraclor's Liccrtsc Law). <br />_l am cxempt undcr B. & P.C. for this rcason. <br />( )rvrrt'r. <br />WORKT'RS' C()MPENSATION <br />DECI ARATION <br />I hcreby affirm under penalty of pcrjury one of thc following declarations: <br />-l <br />have and will maintain a Certificate of Consent to Sclf-lnsure for workers' compensation. as provided for by Section 3700 of the <br />[:bor Code, for thc pcrformance of the work for which the prmit ls issucd. <br />_l have and will maintain workers' compensalion insurance. as requircd by Scction 3700 of thc l-abor Codc, for the pcrformancc of <br />thc work for which this pcrmit is issued. My workers' compcnsation insurance carrier and plicy number are: <br />_l ccrtify that in the pcrformancc of the work for which this permit is issucd. I shall not cnrploy any pcrson in any manncr <br />so as to bccomc subjcct to the workers' compcnsation laws of California. and agrec that if I should bccome subjcct to the <br />workcrs' compcnsation provisions of Scction 3700 of thc l^atnr Code. I shall, forthwith cornply with those provisions.. <br />WARNING: Failure to sccure workcrs' compcnsation covcragc is unlawful, and shall subjcct an cmployer to criminal pcnaltics and <br />civil fincs up to one hundrcd thousand dollars ($100.00t11. in addition to thc cost of compcnsalion. damages as providcd for the <br />NECLARATION <br />I hcrcby affirm undcr penalty of perjury that I am liccnscd undcr provision of Chapter 9 (cornmcncing with Scction 7000) of Division 3 <br />of thc Business and Profcssions Codc, and my liccnse is in full forcc and effect. <br />--Ov1q3Liccnsc\Nurnbcr:3 <br />W <br />I hcrcby affirm undcr pcnslty of perjury that thcrc i! a @nstruction bnding agency for thc Jrcrfomcc of thc work for which this pemit is <br />issucd (Sc. 3097, Civ. C.). <br />lrndcr's Narnc: <br />[-cndcr's Address: <br />APPLICANT DECI ARATION <br />I trcrcby affrrm undcr penalty of pcrjury one of thc following declarations: <br />Dcmolition Pcrmits-Asbestos Notification Federal Rcgulations (Title 40. Parl6) <br />a <br />,2l-Reeuirea <br />l.etter of Notification <br />f t certifl that the federal regulations regarding asbestos removal arc not applicable to this projc.ct. <br />J( ccrrify rhat I havc rcad rhis and statc that the ahove infonnation is corrcct. I agrce to comply with all City and County <br />ordinanccs and Statc laws rclating to rcprcscntativcs of this City and County to cntcr upn thc <br />abovc mcntioned propcrty for <br />Applicant or <br />Permitee natrle <br />and hereby <br />- <br />o,r", ?f t?lZl <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 A lt Drt <br />Bondinq I Groundinq / UFER T,4l /t WTIil)'lo" <br />Transformers I <br />Torqueinq <br />Sub-Panels I <br />AirConditioners l^,lt <br />Roof Top Equipm entlDlAf 'lal ,?l AD <br />Factory Wired Unit l- !lt <br />Walls (Conduit) l <br />Walls (Rouoh) <br />Ceilinqs (Hard & Soffit Rouqh <br />Ceilinqs (T-Bar Rouqh) <br />lVleter Release <br />Rough , <br />Service [Vleter L l^^,d <br />FINAL I ta <br />Notes, Remarks, Etc.I -l <br />[Jn,, nO n7 Onl tr <br />t_ <br />I ,l^ I <br />, <br />I <br />'l'nla <br />-tPolicy*un Expires: ql,IZZ