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ELECTRICAL-INSPECTOR RECORD <br />APPROVALS DATE !D/SIG.COMMENTS OWNI.]R IITJII,DI'R I)l.]I,CARATION <br />I hereby affirnr unJer penulty of 1rrjury that I anr exeDpt frcm lhe Cbntracton' Liccnse law for thc following reason (Scc.7031.5 <br />Ilusincss and Proltssion Codc): Any City or County which rcquircs a pcrmit k) construcl, altcr, irnp()vc, dcmolish ot rcpair any <br />structure, pri(,r k) its issuanca. also requires thc aplllicailt tor such pef,rrit to file a sits[ed stalerrcnt that lE or she ir liccilsed pursuant <br />lo rhc previsions ol tlE Conirack)r's l,iccnscd lnw (Chaptcr L Commcncing with Scction 7tru0 oI l)ivision I ol thc Businc$s and <br />ProfessionsCodc)orthurheorsheisexeDrpttlerelionrandtlEbasisfbrtlrcallegedexen4nior. Anyviolali(DofSectiutT03l.5byauy <br />.pplicinl for a pcnnil sub.jccts the rpplicilnl 10 d civil penalty of not mre lhan five hundred dollars ($50(J). <br />_1. s owncr oI thc proFny, or my ernployccs with wagcs as thcir sle cohpcnsation. will do thc work ard tha stMtuc is frtr <br />intcftlcd or olTercd for slc (Sa.7044, Busincss and Prcfcssions Codc: Thc Conlraclor's Liccns kw d@s not apply to e owncr of <br />tlE pmFny wlD huild3 (rr itr{rows lhermn. ud wln d@s such work himelf or l*rslf or thruuth his or her own efiployees, <br />provided that such improvcmots m fr{ iilcftlcd or olfcN-d for ssjc. li howcvd, (lrc boiHing or ifiprovcmn( is $ld within one ]ca <br />ofcotrplcrio( thc Owrcr Buildcr will luvc t}E burdcn ofpmving lhd he or shc dil mt buill or inporc 0E prcpdly for lh. purpo* of <br />sle). <br />_1, as owncr of thc propcny, am cxclusiycly contrlclinB with licensd contractoN to conslrucl lhe proi.tcl (Scc. 7(X4. Busiresr <br />axl kot!:sionCrxle:TheContrack,r'sLicerscLawdr*snotapplytoilownerofprolEdy*hobuildsorinrprov€sthereoil. <br />and *ho contracls for such Fojccls wilh a ContEck)(s) liccnscd pursumt to the Conuactor's Liccnsc [iw). <br />I anr exemnt urder Sectirrt <br />,r,r",q-Zq-UZ0 <br />DECLARATION <br />I hercby afliril undcr pcnalty ofpcrjury onc oftlrc lollowing decldatioN: <br />_l have ild will nuintain a Ccilil'icale of CoDscnt k, Sel[lnsurc for workds' compensation, as providcd for by Scction 3700 of rhe <br />Iabor Code, tor thc pcrfornrece oflhc work lirr which thc pcrnit is issued. <br />_lhavcandwilln)aintainworkers'conrpemalioniDsurancc,as requiredbySeclion3T00oflhcLahorCode,fotlheperfornErceof <br />thc work for which this lErtrrit is issucd. My workcrs' conlpcnsation insurucc cmier and 1rclicy nunrbcr uc: <br />Policy <br />_l ccnify rhar in rhc NrlilrnraNc of rlr w(trk for which this pcrmit is issucd, I shall not cnDloy any pcrson in any manncr <br />$ astobcconEsuhjccttothcworkcas'conlpcnsationlawsofcalifonria,andagrcethatiflshouldbccorrcsuhjccttolhc <br />sorkers' cotrrpeosttion prorisior$ of Scclion l?00 of the hbor Code, I shall, fonhwith comply wilh lhos ptovisions.. <br />WARNING: Failurc to scur. worlicrs'cotnpcnsation covctagc is unlawful, and shall subjet an cmploycr to riminal pcmhts and <br />civil firEs up h ulc hundrcd rhousahd dollars ($100.000). in addition to lhe cost of compcNtion, danBges s providcd for lhc <br />Section 1076 ofthc t tu Codc. intercs( and dtorrcy s [ccs. <br />o,,", Q-241'ZOLO <br />I hereby aflirnr under pnaltyof pcr.iury that I anr licen*d under povision 9 (conrnEncing wilh Scction 7000) ofDivision 3 <br />of the Business and Profcssions Codc. and my liccnse is in full forc and effect. <br />Licerrsc Clr.*:-LiceDie Nunrber: <br />- <br />Dste <br />- <br />Contmctor: <br />@ <br />issuer.l lSec. l(r97. ('iv. C.). <br />lrnder's Nanrc <br />kndcr's Addrcss: <br />@NI,.DEELABA'IION <br />I hrEby ttllilm undcr frnalty of pcrjury onc of thc li)ll(,wing d6lilations: <br />Dcnmlition Pcrmits-Asb(sk,s Notificaliiln Fcdctal RcBulalions (Titlc 40. Pd6) <br />_Requircd lxllcr of Notilicalion <br />_l cdily (hal rhc tcdcralrcgulations rcgildinS asbcsbs rcrmval dc not applicablc to this prcjct. <br />-l <br />ccnify lhal I lurvc rt-atl this applicali([ ild stalc lhal lhc ah)vc informlion is co[ect- I agre to conply <br />I rcprc*mativcs ofthis Ciry <br />wilh all Cily aod County <br />and County h colcr upon thk <br />Q-zo -zozo <br />ordinanccs md Slatc ljws rclatinS k) <br />abovc trcntioned pmpeny lor <br />Applicana or Agmt <br />Pcmrilcc nqnrc <br />conshclion, and hcrcbJ, autlnrizc <br />Site-Work <br />Underqround <br />Pole Bases <br />Lioht Standards <br />Spas, Pool, Fountains <br />Siqns (monument) <br />Life Safety /Low Voltage <br />Fire Alarm / Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor <br />Bondins / 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 (Rouqh) <br />Ceilings (Hard & Soffit Rough <br />Ceilings (T-Bar Rough) <br />lMeter Release <br />Rouqh <br />Service lVeter <br />F!NAL /0 -'7ao [- Crct vf Aos ry-y <br />Notes, Remarks, Etc. <br />Rev.0B-07-2015