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ELECTRICAL.INSPECTOR RECORD no n7 1n,t s, APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION I hocby affm undr pcnalty of pcfjury that I m exmpt frem thc ContractoB' Licw larv for thc following lleo (Sc.7031.5 BGin6s ild Profsion Code): Any City or County rvhich requirc a pcmt to comiruct. altq. imprcvq &molish or rcpair uy strucruc prior to its issumcc. also rcquirs thc applicilt for such pentrit to file a signqd statflmt that hc or dG is licoscd pcumt to thc previsioN of thc Contractor's Liccnscd Law (Chapt6 9. Comencing with Setion 7000 of Division 3 of thc Busins ed Prcfe$ions Codc) or that hc or shc is cxcmpt thqefrom od thc b6is for thc allcged ermption. Any violation of Setion 7031.5 by my applicantforapemitsubjetsthc applicanttoacivilpcnaltyofnotmorethufivehundrcddollus($500). - -1. as owner of the properly. or my employees with wages as their sole compensation. w'illdo the work and the struclure is not intended or offerd for sale (Sec.7044. Business and hofessions Code: The Contractor's License Larv does not apply to an owner of the p,ropary rvho builds or impro!'es theron and rvho does such uork himself or herself or through his or hcr own employees. provided that such improvoncnts are not intended or offerod for sale. lf. how'wer. tlre building or improvemert is sold within onc year of cornplaion. the Orvner Builder will have the h.rden of proving tha he or she did not build or improve the property for the purposc of sale). - l. as owner of the propaly. arn exclusively contracting rvith licensed contractors to construct the and hofession Code: The Contraclor's License Law does not apply to an owner of property who pr<rject (Sec. 7044. Business builds or improves lhereon. and rvho contracts for such projects rvith a Contracto(s) licensed pursuant to the Contractor's Larv). ___l am e.\â‚¬mpt under B.&a Z DECLARA'I'ION I hereby affrm under penalty of perjury one of the follorving declarations: ---l have and will maintain a Cerri{icate oflConsent to Self-lnsure for workers' compensation. as provided for by Section 3700 of the l-abor Code. for the perfonnancc of the rvork for which the perrnit is isiued. -l have and rvill maintain u'orkers' compensation insurance. as required by Section 3700 of the labor Code. for the pcrformance of the rvork for which this perrnit is issued. My workers' compensation insurance carrier and policy number are: ('lrrr icr : Policy Number:-l:rpires: I certify that in the perforrnance of the rvork for rvhich this permit is issued. I shall not ernploy any person in any manner so as lo becorne subject to the workers' cornpensation larvs of California. and agree that rvorkcrs' cornpensation provisions of Section 3700 of the [abor Code. I shall. forthrvith if I should become subject to the provisions..conrply ,' WARNING: Failure lo scturc u'orkers' compensation coverage is unlarvful. <r- an onployer and civil l-rnes up to one hundrcd thousand dollars ($100.000).compensation.for the .)Section .1076 of the and /- I hereby affrnn under penalty of perjury that I am licensed provision of Chapter 9 (cornrnencing with Section 7000) of Division 3 of the Business and Professions Code. and my license is in full force and effect. License Class:__[.icense Nurnber: l\., i ^.Contraclor: CONS RUCTION LENDING AGENCY I haeby aflirm unda pmahy of pojury that lh@ is a con$rucrion lmding agocy for the pofomilce of the work for s'hich this lumit b issued (Sec. 3097. Civ. C.). Lender's Name: Lcnder's Address: APPLICANT NECLARATION I ho$y affu:n under penalty of perjury one of the following declarations: Demolition Perrnits-Asbestos Notification Federal Regulations (Title 40. Part6) -Required Letter of Notilication -l certify that the federal regulations regarding asbestos removal are not applicable to ____l corify that I have read this application and state u'ith all City and County ordinances and State Laws relating to City and County to enter above mentioned property for Applicrnt or Agent l'crrrrilee na me (print): ,/ the Site-Work Underground Pole Bases Light Standards Spas, Pool, Fountains Signs (monument) Life Safety /Low Voltage Fire Alarm lDarxpers Communications Cable Buildins Under Slab / Floor Bonding I Grounding / UFER Transformers Torqueing Sub-Panels Air Conditioners Roof Top Equipment Factory Wired Unit Walls (Conduit) Walls (Rough) Ceilinss (Hard & Soffit Rouqh Ceilings (T-Bar Roush) Meter Release Lg.D Y Dv<tvt* ?z-q.- Q- ?t Mr"$ult Rough Service Meter FINAL Q-4-Zl D.r-P cl Z Notes, Remarks, Etc. 7llale:l of