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ELECTRICAL.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNDR IIUII,DER I)EI,CARA]]oN <br />I hcrcby alllrnl undcr pcilally ol perjury lhal I am excnllil lionl lhc Cotrlraclors Liccnsc Law for lhc li)lbwing rctson (Scc.7031.5 <br />Busincss axl Prolession C(dc)r Any Cily or Counly which rcquircs n ff,nnil k) conslruct. altcr. inprcvc. dcnrclish or rcpair any <br />struclure. priu lo il$ issuancc. also rcquircs thc appliclnl for such prnrit to lllc a signcd slalcnrnt thill he or shc is liccnscd pursuani <br />b thc provisions ol'thc Contrackr's Liccrlscd Lnw (Chapter 9. Conrnuncing wilh Scctfun 7(x){) of t)ivision .l of rhc Business and <br />Profcssions Codc) or that hc or shc is cxcmpt thcrcftoil] and lhc hnsis lbr thc allcgcd cxcnrplion. Any violatkn of Scction 70.1 1.5 by any <br />applicantloropcrNilsuh.ieclslhe applicanlbscivilpcDtllyofnoltrrcrcthailfivchundrcddolhrs(S5(X)). <br />-1. <br />as owncr of lhc proFErty. or my cmployces with wagcs as thcir sole comlrtrsrli(nl. will d() thc work and llrc slnrcturc is txil <br />inlendcd orollcrcdforsalc(Scc.7(ll4.BusiilcssnndProfcssionsCodc:ThcConlrrcloisl,iccnschtwdocslolflnplylotnownerof <br />the pmFf,y who builds or inprovcs lhcmn. and who d@s such work him(clfor hersclfor through his or her owil crnpk)yccs, <br />providedthatsuch improvemntstrcnotinlcndcdotolltredforsah.lihowcrcr.thehuildingorinprovenEntissoklu'ithinonclctr <br />ofconlplclion. lhc Owncr Buildcr will hsvc thc burdcn of provirrg tlut hc or shc di(l n(il huild or inrprovc thc pmpcny for thc purF)sc of <br />salc). <br />_1. rs oslrcr ol thc prrpcrly. unr cxclusivcly conlracl irg $'ilh Iiccnscd c()nlracl()rs lo con\lruct lhc pt()jccl (Scc. 7(Il.l. llusrncss <br />rild qho conlracts li)r such projects with a Corilrackrr(s) licenscd pursnnnl kr lhc Co0lrncl(tr''s l-iccnsc Law). <br />I xilrcxcrilDl uilJcr Sccl l]. & I'.C. lin lhi\ rer\0tr. <br />Dsle:_ Owner:_ <br />WORKERS' COIlIPENSA'TION <br />DECI ARATION <br />I hcrcby ulfirnl undcr pcnnlty ofpcrjury onc olthc lblhrwing dcclarations: <br />-l <br />havc md will nuirlrin a Certillcatc of Consenl lo Scl[-lilsurc for workcrs' conrpcnsation. as p()vidcd Iitr by Scclion .]700 of the <br />[a?xrr Ctxlc. for thc pcrformilncc of lhc work lor which lhc pcrntit is issucd. <br />-lhavcandwillmainlainworkcrs'compcnsnlioninsurancc.As <br />rcquiredbyScclio[3700ofthe[-aborCodc.tbrthepcrli)rmnceof <br />thc work for which this fcrilil is issucd. My workcrs' conrlcnsatt)n insuroncc curicr and folicy numhcr uc: <br />caricr: Tvrlth <br />-l <br />ce(ily thal i[ lhc pcrloilndtrce ol lhc work lin which lhis pcrnril is issucrl. I shlll n(rl cn]lrloy rny l)c'rson in ary nrrnlcr <br />\o x\ lo hcconrc suhjccl h lhc workcrs'conDcnsation hws ofCalili)rlir. nn(l ngrcc lhal if I should hccotrlc \uhjcct t() tlE <br />workcrs' conrpcnsalion provisions of Scction 37(X) ofthc l-rtnr Codc. I shall. linlhwilh conrply wirlt lho\c pn)!i\ioil\.. <br />WARNING: Failurc to *curc workcrs'conlpcnstrtion covcr^gc is ulla$'lul. ntrd shnll subjccl rn cnuk)ycr to critninnl Fnaltics and <br />civil fincs up lo orE hundrcd Ihousand dollurs (SlU).UX)), iD rddition lo thc cosl ol coillfcnsiltion. dilnDgcs xs providcd for lire <br />Scclion 3076 of thc ljh,r Codc, inlcrcst and fltx,rncy s fccs. <br />-r -10 <br />7fiX)) of Division 3I hdcby rl1ifln uldcr pcnrlly ol pcriury 9 (comnrncing with Scctioil <br />of lhc Busincss and Profcssions Codc. artd rny liccnsc is ir full forcc and elllct <br />t;,"n'.ctur* L(O Cab Liccilsc Nunrbcr:L$8 to{ <br />-l contmctor S olc, ci|r-I <br />CONS'I'RUCTION LENDING AGENCY <br />I hcrcby affirm undcr fEnillty ot pcrjury that thcrc is a colslructhn lcnding agcrcy for thc pcrformarcc o[ thc w()rk for which this lrmit is <br />issucd (Scc. 3097. Civ. C.). <br />kndcr's Nanrc: <br />APPLICANT DECLARAl'ION <br />I hercby allirm undcr penalty ol pc{ury onc of thc tirlkrwing dcclarations: <br />Denx)lilion Pcrmits-n sbcsk)s Nolificatkil [:cdcrill Rcgulali(,ns ('fitlc.10. t'arl6) <br />_Rcquircd Lcllcr ol Nolilicotion <br />_l cenity lhrl thc ttdcralrcgulations rcgilrdiDg rsbcslo\ rctnovtl ilrc not applicrhlc lo lhis projccl <br />-l <br />ccnify lhat I havc rcnd this applicalir)n atul stxlc thxl thc atnvc infrrnrration ir corrcct. I agrcc to cr)rnl)ly (,ith illl City ilnd County <br />D,.", -Ll:): lL <br />Site-Work <br />Underground <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 />Bondinq / Groundinq / UFER <br />Transformers <br />Torqueinq <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rouoh) <br />Ceilinqs (Hard & Soffit Rouqh <br />Ceilinos (T-Bar Rouoh) <br />Meter Release <br />Rouqh ltr -44Cn <br />Service Meter <br />FINAL v-z/ lnq FLp <br />Notes, Remarks, Etc. <br />t)^r, fla n7 ,al E <br />0.,,.r*,,,,*,, w( o u L0l{-ob r.^p**, n-vlL <br />lxndcr's Addrcss: