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ELECTRICAL-I NSPECTOR R ECOR D <br />APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DELSIRATION <br />I hercby affirm under penalty of perjury th.t I m cxempt from thc ContrrcloB' Liccns trw for thc followirg rcasn (Se.7031.5 <br />Busincss and Profcssion Codc): Any Cily or County which rcquircs a Jrcrmit to @nstruct, altr, imprcrc. dcmlish or EJEir oy <br />structurc, prior to its issurec. also rcquircs the applicmt for such pcrmit to lih a signcd slatemnt that hc or slrc is liccn*d pwant <br />to thc pmvisions of thc Controctor's Liccnsd law (Chaptcr 9, Commncing wilh Sstion 70@ of Division 3 of the Busircss and <br />PrcfcssionsCodc)orthathcorshciscxcmptthrcfrcmadthcbasisforthcallegedcxcmption. AnyviolationofSNtion?031.5byany <br />applicrnt for 8 lprmit subjccls the applic&nl to a civil penslty of not mrc the five hundrcd dollus ($500). <br />-1. <br />as owncr of thc propcrty. or my employccs with wagcs as thcir soh comlrcnsation. will do thc work and thc struclurc is not <br />intcnded or offcrcd for salc (Scc.70t4, Business and Professions Codc: The Contractor's License law docs not apply to an owner of <br />thc proprty who builds or improves thcrc$n. and who docs such work hirnsclf or hcrsclf or through his or hcr own employccs, <br />providcd that such improvcnrnts arc not intendcd or offcrcd for salc. lf. howcver. thc building or improvcrrnt is sold within one )aar <br />of cornpletion. thc Owner Buildcr will have thc burdcn of proving th,at hc or shc did not build or inprove thc propcrty for thc purynsc of <br />sah). <br />-1. <br />as owncr of thc propcrty. am cxclusivcly contracting with liccnscd contractors to construct the projcct (Scc. 7W, Busincss <br />and Profession Codc: Thc Conlractor's Liccnsc Law does not apply to an owner of proJrcrty who builds or improvcs thereon. <br />and who contracts for such prop.cts with a Conlraclo(s) licenrcd pursuant to thc Conlraclor's Liccnsc L:w). <br />-IamexcmptunderSection-'B.&P.C.forlhisrcason.Date: Owner: <br />WORK I'RS' C()TTT I'ENSATI( )N <br />DFCLARAI'ION <br />I hcrcby alllrrn undcr pcnalty of perjury onc of thc following dcclarations: <br />-l <br />havc and will maintain a Certificatc of Consent to Sclf-lnsure for workers' comlrcnsation, as provided for by Scction 3700 of thc <br />L:bor Code. l'or the pcrformancc of thc work for which thc Jrcrrnit is issucd. <br />-l <br />have and will maintain workcrs'conlpcnsation insurance. as rcquircd by Section 3700 of the L^abor Code, for thc pcrformancc of <br />the work for which this pcrmit is issucd. My workers' compcnsation insurancc carrier and policy numbcr are: <br />Policv Number: Exoires: <br />-l <br />ccrtify that in the pcrformancc of thc work for which this prmit is issucd. I shall not cmploy any pcrson in any manner <br />so as to bcconrc subjcct to thc workers' comlrcnsation laws of California. and agrec that if I shcruld bcconre subject to thc <br />workcrs' comlrcnsation provisions of Scction 3700 of thc labor Code, I shall. forthwith comply with tlrosc provisions.. <br />WARNING: Failure to sccurc workers' compcnsation covcrage is unlawful. and shall subjcct an cmployer to criminal ;rcnaltics and <br />civil fincs up to one hundrcd thousand dollars ($100.ffi0). in addition to thc cost of compensation. damagcs as providcd for the <br />Scction 3076 of the [:bor Ccxlc. intercst and attorney's fccs. <br />Date: <br />LICENSED CONTRACTOR <br />DECII\RATION <br />I hcrcby affrm under pcnalty of pcrjury that I am licenscd under provision of Chapter 9 (comnrcncing with Sc.ction 7m0) of Division 3 <br />of the Busincss and Professions Code, and my license is in full forcc and cffect. <br />License Numbcr: <br />Dale: <br />W <br />I hcrcby affirm urdcr pcnalty of Frjury that thcrc is a onstruclion lcnding lgcrcy for thc trcrfotl@cc of lhc work for which lhis ]Emit is <br />issucd (SE. 3097. Civ. C.). <br />[.cndcr's Namc: <br />lrnder's Address: <br />APPI TCANT DECLARATION <br />I hcrcby affrrm under pcnalty of pcrjury onc of thc following dcclarations: <br />Dcmolition Pcrmits-Asbcstos Notilication Fcdcral Regulations (Title 40. Part6) <br />_Rcqu ircd l-cttcr of Notification <br />_l certity that thc t'cdcralrcgulations rcgarding asbcstos renrovalarc not applicablc to this projcct. <br />_l ccrlify that I h!rc rcad Ihis spplicalion srd state that thc abovc informtion is corct. I agrc to emply with all Cily ard County <br />ordinarccs and Slatc hws rclating to building construcliotr ard hercby authorizc rcprcrntativcs oflhis Cily and County to ent6 ulnn thc <br />[bovc rcntiorcd prcpeny for inspcrtion purposs. <br />Applicant or Agent <br />Pcmlte Ere (Drht): <br />Site-Work <br />Underground <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Signs (monument) <br />Life Safety /Low Voltaqe <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under SIab / Floor 7, <br />Bonding I Groundins I UFER DKy-IY / <br />Transformers <br />Torqueing <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouqh) <br />Ceilinss (Hard & Soffit Rouqh <br />Ceilings (T-Bar Rough), <br />N/eter Release U -15 7 (" Dtkt v5? <br />Rough <br />Service N/eter bvi'*{/ <br />FINAL o (. f'rVl-*Y <br />Notes, Remarks, Etc <br />Dr.., nO Dn{ tr <br />Carrier: