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ELECTRICAL.I NSPECTOR R ECOR D <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hercby aflirm undcr pcnalty of pcrjury that I m cxcmpt from lhc Contractors' Licen$ kw for thc following rcasn (SN.7031.5 t <br />Busincss Brd Profcssion Codc): Atry City or County which rcquircs a lrcrmit to @nstruct. altcr. improrc, demlish or rcpair any <br />slructrc. Fior to its issuarcc. also rcquircs thc applicanl for such lrcrmit to lilc tr signed slatcmnt lhal lE or slrc is liccnsd pusuant <br />lo the pmvisions of thc Contrsctor's Liccnrcd lau (Chaptcr 9. Comrcncing wilh Sstion 7000 of Division 3 of thc Busincss md <br />PrufcssionsCodc)orthathcorshciscxcmptthscfmmmdthcbrsisforthcalhgcdcxcmption. AnyviolationofsectionT03l.5byony <br />opplicant for a lrcrmit subj$rs the applicsnt to a civil pcnalty of not mrc than fivc hundrcd dollds ($50o). <br />_1. as owncr of thc propcrty, or my cmployces with wagcs as thcir solc compcnsation. willdo thc work and thc stritcture is not <br />intcndcd or ofl'cred tbr salc (Sec.7044. Business and Prot'essions Codc: Thc Contractor's Licensc law docs not apply to an owncr of <br />lhc propcrty who builds or inrproves thcrcon. and who does such work himself or hcrsclf or through his or hcr own cmployccs. <br />providcd that such improvcnrcnts arc not interded or olTcrcd for sah. lf. howcvcr. thc building or inrprovcrrnt is sold within onc )rcar <br />of comphtion. the Owncr Builder will havc thc burdcn of proving that hc or she did not build or inprove thc propclty for the purposc of <br />salc). <br />_1. as owncr of thc propcrty. am exclusively contracting with liccnscd conlraclors lo construct thc projcct (Scc. 7W. Busincss <br />aml hrcfession Code: The Contractor's Liccnse Law does not apply to an owncr of prolrcrty who builds or improves thcreon, <br />and who contracts for such projccts with a Contracto(s) liccnscd pursuant to thc Contractor's Licensc l-aw). <br />-IamcxcmptundcrSection-.B.&P.C.forthisreason. <br />f lol n. <br />WORKERS' COMPENSATI(IN <br />DECLARATION <br />I hereby affirrn under pcnalty of pcrjury onc of thc following declaralions: <br />_l havc and will maintain a Certificatc of Conscnt to Sclf-lnsurc for workers' compcnsation. as providcd for by Scction 37fi) of thc <br />Labor Codc. ftrr the pcrfornmnce of thc work for which the pcrmit is issucd. <br />-l <br />havc and will rnaintain workcrs' comlrcnsation insurarrce. as rcquired by Scction 3700 of thc l-abor Codc, for the lxrfornrancc of <br />which this prmit is iszued. My workers' compensation insurancc carricr and plicy numbcr arc:-,Cf ir<, (w\L< 1)- <br />thc work for <br />Carricr: <br />poricy *"^*, - 3l{(eEo3 ( Expires: CC/Z ( f zo^ c- <br />-l <br />certify that in the pcrformancc of thc work for which this permit is issucd, I shall not cmploy any pcrson in any manncr <br />so as to bccomc subject to thc workcrs'compensation laws of California. and agrce that if I should bccome subjcct to the <br />workers' compcnsation provisions of Scction 3700 of the l-abor Code. I shall. forthwith comply with thosc provisions.. <br />WARNING: Failurc to riccurc workcrs' compcnsation covcragc is unlawful. and shall suhjcct an entploycr to criminal pcnalties and <br />civil fincs up to one hundrcd thousand dollars ($100.000). in addition to thc cost of compcnsation. danugcs a.s providcd for thc <br />Scction 3076 of thc Labor Codc. intcrest and attorrrcy's <br />Z\han <r-t' <br />DECLARATION <br />I hcrcby affirrn undcr pcnalty of perjury lhat I am licenscd undcr provision of Chapter 9 (comnrcncing with Scction 7000) of Division 3 <br />of the Busincss and Profcssions Codc, and my liccnsc is in full force and effccl. <br />Liccnse <br />(--ld <br />Nurnbcr:O6 <br />'{o'L C/- <br />W <br />I hcrcby sffirm under pcnalty of lErjury that thsc is a @nstruclk n lcnding .gcrcy for the pcrfomce of Ihe work for which this lrmil ir <br />issucd (Ss. 309?. Civ. C.). <br />[.cnder's Name: <br />hndcr's Addrcss: <br />APPI ICANT nr.Ct ARATTON <br />I hcrcby allirm under pcnalty of pcrjury one of thc following dcclarations: <br />Dcmolition Pcrmits-Asbcstos Notification Federal Rcgulations (Titlc 40, Part6) <br />_Rcqu ircd l,ctter of Notification <br />t <br />_l ccrtify that the fcdcral regulations rcgarding asbcstosqgmovalarc not applicable to this pr<rjcct. <br />_l certify thal I have rcad this application and state that thc abovc information is corrcct. I agrcrc to comply with all City and County <br />ortlinanccs :rntl Statc Laws of this City and County to cntcr uJxln thc <br />abovc mentioncd property for <br />Applicant or Agent <br />I)cmritee natne <br />building and hcrcby authorizc <br />d Lq ) <br />Site-Work <br />Underground <br />Pole Bases <br />Liqht Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safety /Low Voltase <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under Sl ab I Floor I <br />Bonding I Groundins I UFER loY&1dr >tru>/ <br />Transformers <br />Torqueinq <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factorv Wired Unit <br />Walls (Conduit) <br />Wails (Roush) <br />Ceilings (Hard & Soffit Rouqh <br />Ceilinqs [-Bar Rouqh) <br />N/eter Release tvl-uq,9Wyy <br />Rouqh <br />Service N/eter I I <br />FINAL IBI ?UA fiftry2 / <br />Notes, Remarks, Etc.I I <br />r OCI n7 On1 tr <br />Lnj